Diagnostic Assessment — Right Temporomandibular Joint Dysfunction
Example 1 of 1 · fictitious patient (Veteran R)
Diagnostic Assessment
Right Temporomandibular Joint Dysfunction
Balance of Probabilities: Temporomandibular Disorder No. 46 of 2018 Reasonable Hypothesis: Temporomandibular Disorder No. 47 of 2018
ADF History
The veteran, Aircraft Mechanical - AB, 30 October 1981, 09 Apr 1986.
Occupational History
Aircraft mechanics in the Royal Australian Navy are exposed to various occupational hazards including vibration from tools and equipment, awkward working positions in confined spaces, manual handling of heavy components, exposure to chemicals and solvents, and potential trauma from moving aircraft parts and machinery. The role requires working in cramped conditions which can place stress on joints and musculoskeletal structures, and may involve activities requiring prolonged flexion of the head and shoulder when working on aircraft components.
History
The veteran an Aircraft Mechanical in the Royal Australian Navy, sustained severe facial trauma including temporomandibular joint injury in a motor vehicle accident on 14 Jun 1983 while travelling to work, resulting in ongoing temporomandibular joint dysfunction.
Timeline
- 14 Jun 1983: Motor vehicle accident occurred while travelling to work from St George to Nowa. fractured his orbit, zygoma and mandible with severe temporomandibular joint trauma requiring immediate hospitalisation and emergency medical intervention.
- 31 December 1983: Major reconstructive surgery performed at a private hospital involving exploration of the right temporomandibular joint through temporo-facial incision, with extensive joint reconstruction including osteotomy of the condylar neck and temporalis muscle transfer arthroplasty to address the severely damaged joint structures.
- February 1987: Follow-up surgical procedure for removal of intermaxillary fixation wires under local anaesthetic, with restoration of occlusion following extended period of jaw immobilisation necessary for healing of the reconstructed temporomandibular joint.
- November 1987: Condition documented as permanent and stable with ongoing severe Temporomandibular Joint dysfunction characterised by inability to chew normally, altered jaw mechanics, and persistent functional limitations affecting daily activities.
- July 2018: Recent comprehensive imaging studies confirmed chronic temporomandibular joint pathology with old healed fracture of the right mandibular condyle and secondary degenerative changes including disc degeneration and muscle atrophy consistent with long-standing temporomandibular disorder.
Symptoms
At the time of injury, the veteran experienced severe orofacial pain, inability to close his mouth properly, marked swelling and bleeding, and complete loss of normal jaw function due to multiple facial fractures including temporomandibular joint disruption. Post-injury symptoms included severe temporomandibular joint dysfunction with inability to chew on the right side, absence of jaw power with sensation of dislocation during any chewing attempts, numbness and tingling of the bottom lip with drooling, dysarthric speech due to restricted mouth opening, significant weight loss of 19kg, frequent nosebleeds, and recurring migraines starting behind the right eye. Currently, he continues to experience severe temporomandibular joint dysfunction with abnormal movement patterns, persistent sensation of joint dislocation during chewing, ongoing numbness and paraesthesia of the lower lip, altered bite mechanics, speech difficulties due to restricted jaw opening, and significant functional impairment affecting eating, social interaction, and occupational activities requiring oral communication.
Imaging
July 2018: MRI temporomandibular joints revealed impression of old healed fracture of the right mandibular condyle with some sclerosis and osteophytes, suggestive of secondary mild-to-moderate osteoarthritic changes with disc degeneration and atrophy of the muscles of mastication.
July 2018: Ultrasound bilateral jaw demonstrated minimal suppression noted at the open right TMJ with maintained capsule integrity and large suppression noted within the left TMJ with poor definition of the capsule suggesting chronic subluxation with associated tenderness.
1. What is the formal diagnosis of the condition claimed above?
Right Temporomandibular Joint Dysfunction - SOP Code: Temporomandibular Disorder No. 47 of 2018 (RH), No. 46 of 2018 (BOP), ICD-10 Code: M26.60
Temporomandibular disorder represents a heterogeneous group of conditions affecting the anatomical and functional characteristics of the temporomandibular joint, masticatory muscles and associated structures of the masticatory system. The condition is characterised by clinically significant pain localised in the temple, front of ear or jaw that is modified with jaw movement, clinically significant distress or substantial impairment of social, occupational, educational or other important areas of functioning due to pain, limitation, deviation or other abnormality of jaw motion, and clinical signs or imaging evidence of myalgia, arthralgia, or another pathological process affecting the temporomandibular joint and associated structures.
2. For each diagnosis identified, please also provide the following dates:
When did the veteran first experience symptoms attributable to this condition?
The veteran first experienced symptoms of temporomandibular joint dysfunction immediately following the motor vehicle accident on 14 Jun 1983 [CIA1 - the veteran the veteran - COMBINED - COMPLETE.pdf, multiple pages].
When did the veteran first present to a health / medical provider for this condition?
The veteran first presented for emergency medical care on 14 Jun 1983 immediately following the motor vehicle accident to hospital medical officers [CIA1 - the veteran the veteran - COMBINED - COMPLETE.pdf, medical records].
When was the condition confirmed / formally diagnosed?
The temporomandibular joint dysfunction was confirmed during surgical exploration on 31 December 1983 by Professor at a private hospital, who documented the severely damaged joint requiring extensive reconstruction [CIA1 - the veteran the veteran - COMBINED - COMPLETE.pdf, surgical reports].
When did the veteran first present to you (or your practice) for this condition?
15 February 2015
3. How was this diagnosis confirmed? i.e. what were the key symptoms and signs, investigation results, specialist opinions? Please attach any relevant correspondence and investigation results.
The diagnosis was confirmed through clinical examination revealing severe functional impairment of the temporomandibular joint, inability to chew normally, altered jaw mechanics, and restricted mouth opening. Surgical exploration in 1990 confirmed extensive joint damage requiring complex reconstruction. Recent imaging studies in 2021 demonstrated chronic post-traumatic changes including condylar fracture sequelae, disc degeneration, and secondary osteoarthritic changes consistent with long-standing temporomandibular disorder [CIA1 - the veteran the veteran - COMBINED - COMPLETE.pdf, surgical and imaging reports].
4. What do you consider to be the cause(s) of the condition in this veteran? Give consideration to constitutional and common risk factors, pre-existing injuries or diseases, and occupational or lifestyle risks, as well as direct causative mechanisms.
Right Temporomandibular Joint Dysfunction - Reasonable Hypothesis Factors:
Having acute trauma to the affected temporomandibular joint, masticatory muscles and associated structures of the masticatory system, within the 30 days before the clinical onset of temporomandibular disorder - MET
- The motor vehicle accident on 14 Jun 1983 constituted acute trauma involving significant physical force applied to the temporomandibular joint and associated structures, with immediate onset of symptoms and clinical signs consistent with the SOP definition of acute trauma.
Having a specified joint disease involving the affected temporomandibular joint, at the time of the clinical onset of temporomandibular disorder - MET
- The traumatic injury resulted in joint damage and subsequent development of osteoarthritis of the temporomandibular joint, which falls under the category of specified joint disease as defined in the SOP.
Right Temporomandibular Joint Dysfunction - Balance of Probabilities Factors:
Having acute trauma to the affected temporomandibular joint, masticatory muscles and associated structures of the masticatory system, within the 30 days before the clinical onset of temporomandibular disorder - MET
- The motor vehicle accident on 14 Jun 1983 involved application of significant physical force causing damage to the temporomandibular joint and associated structures, with development of symptoms within 24 hours and persistence requiring extensive surgical intervention.
Having a specified joint disease involving the affected temporomandibular joint, at the time of the clinical onset of temporomandibular disorder - MET
- The post-traumatic osteoarthritis of the temporomandibular joint constitutes a specified joint disease as defined in the SOP, present at the time of clinical onset of the temporomandibular disorder.
Sequelae
The temporomandibular joint dysfunction is not a sequela of another condition but rather the primary manifestation of the traumatic injury sustained in the 1989 motor vehicle accident.
Unintended Consequence
The condition is not considered an unintended consequence of medical management. The surgical interventions were appropriate and necessary for management of the severe temporomandibular joint trauma, representing standard care for such complex injuries.
Inability to Attain Appropriate Medical Management
This factor is NOT MET. The veteran received extensive and appropriate medical management including emergency treatment, complex reconstructive surgery involving temporomandibular joint exploration and reconstruction, temporalis muscle transfer arthroplasty, and ongoing specialist care. The surgical management was highly specialized and appropriate for the severity of the injury and the standards of care available at the time. As established in Brew v Repatriation Commission, there was no objective or subjective inability to obtain treatment, with comprehensive surgical intervention being provided promptly after the injury.
The % contribution of the causes is 100% and significant.
5. Please provide a Health Summary and a medication / prescribing history.
- See attached report
