Case Report: Longitudinal temporomandibular joint remodeling in MMP2 associated nodulosis arthropathy osteolysis syndrome during serial panoramic follow up.

Nodulosis-arthropathy-osteolysis (NAO) syndrome, within the multicentric osteolysis, nodulosis, and arthropathy (MONA) spectrum, is a rare autosomal recessive osteolytic disorder most commonly associated with pathogenic variants in MMP2. Appendicular skeletal involvement is well recognized, whereas temporomandibular joint (TMJ) involvement remains poorly documented. We report longitudinal clinical and radiographic TMJ findings in an adult male with genetically confirmed MMP2-associated NAO syndrome, with the exact variant to be reported using HGVS nomenclature from the genetic report who underwent serial panoramic radiographic follow-up between 2018 and 2026. Over the observation period, panoramic images demonstrated progressive bilateral condylar flattening, cortical irregularity, lateral osteophytic change, shallowing of the glenoid fossae, and marked flattening of the articular eminences. Despite progressive structural remodeling, symptoms remained relatively mild, with intermittent TMJ clicking, mild discomfort, and generally preserved mandibular function. The case is further notable because the patient received long-term intravenous antiresorptive therapy, first with pamidronate and later with zoledronic acid, requiring explicit consideration of medication-related osteonecrosis of the jaw (MRONJ). No documented clinical evidence of MRONJ was identified during follow-up. This case suggests that TMJ remodeling may be part of the craniofacial phenotype of NAO/MONA spectrum disease and illustrates both the value and limitations of serial panoramic radiography. Panoramic imaging can document gross longitudinal osseous change, but the absence of CBCT and MRI limits three-dimensional bony and soft-tissue assessment.