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A 30 year old female patient presented in 2009 with severe bilateral temporomandibular joint (TMJ) pain, restricted mouth opening and tenderness over the masseter muscles. She was initially diagnosed with Wilkes Stage IV of the right and left TMJ. A diagnostic arthroscopy performed bilaterally failed to releave her pain. She was diagnosed with an isolated spondyloarthropathy of TMJ based on a positive test for HLA B. Further medicamentous treatment was unsuccesfull over subsequent months and years. CBCT of the TMJ showed discrete sclerosis of the right TMJ. Based on an additional SPECT-CT with 99 Tcm hydroxymetylene diphosphonate with significant increased uptake of the tracer in the right TMJ, the right TMJ was considered as end stage disease and a right total joint replacement (TJR) using a Zimmer Biomet custom made prosthesis was performed. A left TJR was performed 3 years.