An Alternative Approach for Treating Severe Injured Temporomandibular Joints by Gunshot Wounds


Temporomandibular joint (TMJ) reconstruction is a challenging clinical problem that has been revolutionized due to the development of total alloplastic TMJ replacement (TMJ-TJR); however, the costs are still very high. We used an alternative approach to treat comminuted mandibular condyle fracture with an unviable condyle head caused by gunshot wounds. Our surgical technique consisted of an extended preauricular incision; removal of the fractured condyle, bone fragments, and foreign bodies; reshape/flattening of the fracture edge; fixation of the articular disc (if viable); lining of the TMJ with temporalis muscle/fascia; application of Erich arch bars; and early elastic therapy. We successfully used this approach in five sequential cases that resulted in a good mouth opening (>35 mm) and satisfactory occlusion with teeth in maximum intercuspation. We believe that this technique is an excellent option for treating severe injured TMJs in places where TMJ-TJR is not available.

Case Report

A 20-year-old male patient who was a victim of a robbery and was hit by a gunshot on his zygomatic arch presented with a right comminuted condylar head and zygomatic arch fractures. The treatment was the same as described before and included the removal of the bullet and the condylar head and lining of the temporal fascia/muscle over the TMJ [Figure 4]. Postoperative findings included a slight deviation of the mouth opening to the left side, good maximum mouth opening, and slight dental adaptations.

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Figure 4
Lateral view of the patient and entry gunshot wound (a). Coronal cut and three-dimensional reconstruction from computed tomography scan showing a head condyle fracture on the right side including a foreign body (projectile) (b and c). Surgical approach (d) and lining of the temporomandibular joint with temporalis fascia (e). Removed bone fragment and projectile (f)