CLINICAL STUDIY
Surgical Management of Gunshot Injury to the
Temporomandibular Joint
Marcelo Soares dos Santos, DDS, Kalyne Kelly Negromonte Gonçalves, DDS,y
Caio César Gonçalves Silva, DDS, Demóstenes Alves Diniz, DDS,y
and Belmiro Cavalcanti do Egito Vasconcelos, DDS, PhDz
Abstract: One of the indications of the surgical approach of the
Downloaded from https://journals.lww.com/jcraniofacialsurgery by BhDMf5ePHKav1zEoum1tQfN4a+kJLhEZgbsIHo4XMi0hCywCX1AWnYQp/IlQrHD3be73+7zLk/Sq+y6koaZl6Ep8oGuop87+BJ3Fduo7x/vYXVyjpiSPWQ== on 10/17/2019
temporomandibular joint is the presence of foreign body in its
interior. However, joint handling offers risks, especially bleeding.
In these cases, angiography and embolization of the arteries
involved with the projectile play an important role in the prevention
of complications. In this report, the authors describe a case of a 23-
year-old male victim of firearm attack with comminuted fracture of
the right mandibular condyle. The patient underwent angiography
and prophylactic embolization of the arteries adjacent to the foreign
body. A surgical procedure was performed to remove the projectile
and bone fragments with the aid of the X-ray image intensifier,
which resulted in the restoration of mandibular function, absence of
joint pain, and satisfactory dental occlusion. This case shows the
importance of auxiliary imaging methods for performing a safe
surgical procedure for removal of ballistic and bony fragments from
the interior of the temporomandibular joint.
Key Words: Comminuted fractures, gunshot wounds,
rehabilitation, temporomandibular joint
(J Craniofac Surg 2019;30: 2257–2260)
F irearm projectile (FP) injuries, when they affect the face,
represent a challenge for maxillofacial surgeons, as they are
usually accompanied by loss of soft tissue and severe destruction of
bone.1 These lesions are aesthetically and functionally devastating,
and their severity depends on the type of weapon, the shape of the
projectile, the intensity of the impact and the density of the injured
structures.2
From the Department of Oral and Maxillofacial Surgery, School of
Dentistry, Universidade de Pernambuco, Camaragibe; yService of Oral
and Maxillofacial Surgery; and zDepartment of Oral and Maxillofacial
Surgery, School of Dentistry, Universidade de Pernambuco, and Staff of
the Oral and Maxillofacial Surgery service, Hospital da Restauração,
Recife, Brazil.
Received May 27, 2019.
Accepted for publication August 17, 2019.
Address correspondence and reprint requests to Belmiro Cavalcanti do
Egito Vasconcelos, DDS, PhD, Faculdade de Odontologia de
Pernambuco, Universidade de Pernambuco. Av. Gen. Newton Caval-
canti, 1650, Tabatinga, Camaragibe CEP 54.753-220l, PE, Brazil;
E-mail: belmirovasconcelos@gmail.com
The authors report no conflicts of interest.
Supplemental digital contents are available for this article. Direct URL citations
appear in the printed text and are provided in the HTML and PDF versions of
this article on the journal’s Web site (www.jcraniofacialsurgery.com).
Copyright # 2019 by Mutaz B. Habal, MD
ISSN: 1049-2275
DOI: 10.1097/SCS.0000000000005989
The Journal of Craniofacial Surgery  Volume 30, Number 7, October 2019
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Clark et al3 reported their experiences at the Maryland Shock
Trauma Center and found that among 178 firearm injuries in the
face, 40% affected the frontal bone and skull, 24% multiple sites,
14% maxilla, 13% mandible, and 9% the orbits. The FP-related
trauma in the temporomandibular joint region (TMJ) is associated
with the transfer of a massive amount of kinetic energy, which can
cause damage to local anatomical structures such as bone and
cartilage. These lesions can lead to complications such as edema,
limitation of mouth opening and ankylosis.4
An indication for the surgical treatment of TMJ is the presence
of foreign bodies in the region.5 Thus, in cases of aggression by FP
in the mandibular condyle, the primary management is performed
through extensive irrigation, debridement of the wound and
removal of non-viable bone fragments and shrapnel. Then, after
access to the bone stumps, it is sought to find scattered osseous
segments with the purpose of stabilizing the structure and allowing
fixation. However, this is not always possible, because the bone
tissue is often avulsed or comminuted.6
Furthermore, the handling of TMJ, as in any surgical procedure,
offers risks such as the development of infections, neurological
lesions and hemorrhage.7 The internal maxillary artery and its
branches, in addition to the pterygoid venous plexus, may be
adjacent to the medial aspect of the joint. Even with careful
dissection, these structures can be damaged, leading to a significant
loss of blood. Angiography associated with prophylactic emboliza-
tion of the internal maxillary artery may play a key role in
preventing bleeding in these cases.8– 10
The objective of this study is to report the case of a patient who
suffered a FP aggression which damaged the right temporomandib-
ular joint, where bone fragments and the projectile were removed
from the interior of the glenoid fossa, as well as demonstrating the
importance of auxiliary imaging methods in the management of
this patient.
CLINICAL REPORT
A 23-year-old male patient, light-skinned, was referred to the Oral
and Maxillofacial Surgery Service of the Hospital da Restauração,
Recife, Brazil, a victim of gunshot injury in the face. Patient
claimed he had no comorbidities or allergies. It was evaluated
by the neurosurgery team of the hospital who ruled out any
traumatic brain injury.
Physical examination of the patient’s face showed a perforating
wound in the right auricle pavilion, an increase in volume and pain
in the right pre-auricular region, and a slight limitation of mouth
opening (37 mm), with a right mandibular deviation during the
mouth opening movement (Fig. 1A). Intraoral physical examination
showed right cross-bite, with mandibular midline alteration
(Fig. 1B). Antibiotic therapy (Ceftriaxone 1 g intravenously twice
daily), tetanus prophylaxis (0.5 ml Intramuscular) and analgesia
were done as part of the treatment.
Computed tomography (CT) showed a projectile within the
glenoid fossa of the temporomandibular joint, associated with
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Santos et al The Journal of Craniofacial Surgery
FIGURE 1. A. Mouth opening of 37 mm, with mandibular deviation to right
side. B. Intraoral view of malocclusion with mandibular midline deviation to the
right and posterior crossbite on the right side, with premature occlusal contact.
the comminuted fracture of the right mandibular condyle (Fig. 2).
Based on physical examination and imaging, surgery to remove the
projectile and bone fragments was proposed. In order to minimize
surgery risks, an angiography was requested, which showed an
intimate relation of the FP with the internal maxillary and menin-
geal artery. Thus, 1 day before the procedure, embolization of the
aforementioned arteries was performed using Gelfoam and a
4  10 mm spring proximally (Fig. 3).
The surgery was executed after seven days of initial care, in
order to allow edema regression. The patient underwent general
anesthesia, with nasotracheal intubation. After antisepsis (2%
chlorhexidine) and apposition of operative sites, right preauricular
access was outlined at the junction of the facial skin with the helix of
the ear, in a natural cutaneous fold, and subcutaneous infiltration
with 2% lidocaine with 1:100,000 adrenaline was done. The skin,
subcutaneous connective tissue and temporoparietal fascia were
incised (Fig. 4A). Blunt dissection was then performed anteriorly to
the tragus to the level of the superficial layer of the temporalis
fascia. After its identification, the tissue flap containing the super-
ficial temporal vessels and auriculotemporal nerve was anteriorly
retracted with the aid of Senn-Miller retractors.
Following this, an incision was made through the superficial
layer of the temporalis fascia, obliquely, starting from root of the
zygomatic arch and extending in the antero-superior direction. A
periosteal elevator was inserted into this incision, below the tem-
poralis fascia, and the periosteum of the lateral wall of the zygo-
matic arch was detached. Due to the injury caused by FP, the
capsule of the TMJ was not found in its full integrity. Finally, the
dissection followed anteriorly until the articular eminence expo-
sure, and the flap was maintained with the retractors.
Given the difficulty in locating the projectile, the X-ray image
intensifier was used intra-operatively to obtain the correct position
of the foreign body. After its identification, the projectile was
removed whith a Halsted anatomic clamp, and the cavity was
cleaned with saline solution (NaCl 0,9%) to allow the search for
bone fragments and shrapnel of the projectile (Fig. 4B–D)
FIGURE 2. (A) Axial and (B) coronal section of computed tomography
demonstrating the presence of FP within the glenoid fossa.
2258 # 2019 Mutaz B. Habal, MD
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
 Volume 30, Number 7, October 2019
FIGURE 3. Image of angiography. (A) View in profile and (B) frontal of the
patient, where it is observed intimate relation of the foreign body with the
internal maxillary artery and middle meningeal artery. (C) Image after
embolization of the involved arteries. Note the presence of proximally
positioned rings (arrow).
The remaining condylar bone stump was reshaped with the aid
of wear drills, and the articular disc was dissected and positioned in
the joint fossa of the temporal bone. It was held in position with the
aid of sutures of its lateral aspect to the soft tissue of the zygomatic
arch and to the remnants of the articular capsule, intending to
remain as interpositional tissue (Fig. 4E). The wound closure was
performed by layers, from inside to outside, using resorbable thread
based on polyglactin 910 4-0 (Vicryl) for closure of temporalis
fascia and subcutaneous tissue and non-resorbable Nylon 5-0 for
closure of the skin (Fig. 4F).
After the procedure, the patient was maintained in maxilloman-
dibular fixation for seven days in order to preserve dental occlusion.
After that, elastic therapy was used for another seven days, to
minimize deviations during mouth opening. Post-operative CT
showed no foreign body in the right TMJ region (Fig. 5). The
entire post-operative period was without complications. The patient
was advised to perform physiotherapy with warm compresses, inter-
incisal wooden spatulas for gradual gain of buccal opening range
and passive movements of laterality, opening and closing of mouth.
At the time of writing of this paper, the patient had 10 months of
outpatient follow-up, with good oral opening (40 mm), no painful
symptoms, good occlusion, no mandibular deviation or any kind of
sensory or motor problems (Fig. 6).
DISCUSSION
Injuries caused by firearm projectiles in the craniofacial complex
often result in devastating dysfunctions and severe aesthetic
FIGURE 4. (A) Preauricular surgical access. (B) Frontal view of X-ray image
intensifier used in the trans-operative period. (C) Observation of the projectile at
the surgical site after dissection. (D) Removed bone fragments and projectile. (E)
Remaining reanatomized condylar stump. Observe the articular disc positioned
inside the joint fossa with sutures (arrow). (F) Suture of the skin.
The Journal of Craniofacial Surgery  Volume 30, Number 7, October 2019
FIGURE 5. Post-operative CT.
impairment, which can be increased by the associated psychosocial
trauma. These lesions present an extremely varied pattern, mainly
due to differences between individuals and the amount of kinetic
energy transferred to the patient. High-speed projectiles (>1200
feet per second), such as military ones, are commonly related to the
massive destruction of soft tissue and bone. As in this case, injuries
caused by civilian weapons, which have low-velocity projectiles (<
1200 feet per second), are less harmful but are still capable of
causing bone comminution.11,12
In the authors’ knowledge, there are only 4 cases in the English
language literature about the surgical approach to injury caused by
FPs in the temporomandibular joint (see Table S1, Supplemental
Digital Content, http://links.lww.com/SCS/A938).1,4,13,14 These
lesions, when they cause fractures of the condylar process, may
lead to malocclusion, limitation of mouth opening and laterality,
anterior open bite, mandibular deviation at maximum opening and
protrusion, and, more rarely, ankylosis of the temporomandibular
joint.15 In the case described, due to the decrease in vertical height
of the right mandibular ramus, malocclusion and mandibular devi-
ation to the affected side during opening were present. Although the
patient had a severely comminuted mandibular condyle and the
presence of a projectile located inside the joint fossa, the mouth
opening limitation was low.
It is still widely discussed in the literature whether ballistic
fragments should be removed or not and whether condylar fractures
should be treated open or closed. The approach for the removal of
foreign body inside the TMJ has a strong surgical indication, since
the presence of foreign material causes mechanical blocking of the
condylar movement, besides generating fibroses and erosion in the
ear canal and condyle.5,16 In the studied patient, the open treatment
with removal of the projectile was necessary due to the severe and
non-reducible malocclusion, possibly due to bone impactions with
the projectile present in the site. However, as with Grossman et al1,
it is the opinion of the authors that if the fragment was located in
FIGURE 6. Post-operative dental occlusion, with correction of mandibular
midline deviation and right posterior crossbite.
# 2019 Mutaz B. Habal, MD
Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
Gunshot Injury to the Temporomandibular Joint
hard or soft tissue without causing pain or limitation of function, a
more conservative clinical approach could be chosen.
Surgically, the TMJ should be handled extremely carefully
through correct planning and delicate technique in order to avoid
complications such as facial nerve damage, development of aur-
iculotemporal syndrome (Frey’s syndrome), formation of salivary
fistula, lesions of the ear canal, ankylosis and bleeding.1,17 Blood
loss may be substantial, with volumes as high as 3 liters after
damage to the internal maxillary artery. Moreover, these lesions
may directly interfere with the surgeon’s abilities by hindering
visualization in limited access.9,10 Thus, angiography by computed
tomography was extremely important in our case due to the
observation of the relation of the FP with the internal maxillary
artery. It was an essential imaging examination in the pre-operative
period of the surgeries to remove foreign material from the TMJ.
Following this, it was possible to perform the embolization of the
involved arteries in a prophylactic manner, which allowed a faster,
safer procedure with minimal bleeding, allowing adequate removal
of the ballistic fragment and nonviable remains of bone with
minimal bleeding.
In addition, risk of nerve or vascular injury may exist if the
correct location of a foreign body is not precisely defined. Radio-
graphs and CT scans provide information on the position of an
object only in a static posture of the head, requiring a real-time
trans-operative image to define the exact three-dimensional loca-
tion of the item.18,19 Therefore, because it is a foreign body that is
clinically non-palpable, in an area rich in noble structures and with
anatomy disfigured by local aggression caused by FP, the X-ray
image intensifier was, in our case, used in trans-operative approach.
In the present study, the patient suffered a severe comminuted
fracture of the mandibular condyle that led to the partial removal of
the condylar process. The authors do not know any case in the
literature that describes such an injury under these circumstances. It
was decided to remodel the remaining bone stump and preserve the
joint structure, without reconstruction with alloplastic or autoge-
nous material. As demonstrated by Mehra et al20, low condilectomy
without reconstruction has some advantages, such as preservation
of the joint, avoids additional incisions at donor sites, as well as
shorter surgical and hospitalization time. However, in cases where
trauma involves the condylar process beyond the sigmoid notch,
reconstruction becomes mandatory.
Furthermore, reestablishing the position of the disc plays a
crucial role in the successful treatment of these patients. It will
function as an interpositional graft, directly preventing post-trau-
matic ankylosis by limiting bone contact.21,22 Many types of
materials can be used for this purpose, such as temporal muscle
flaps, skin grafts, autogenous cartilage and silicone. Therefore, the
nature of the articular disc makes it the ideal graft tissue, since it has
sufficient size, adequate thickness and resilience and no risk of
foreign body type reaction. Moreover, the surgery duration is
shorter, it avoids the morbidity of another surgical site and is more
cost efficient.22 In our case, the disc was located with its preserved
integrity and, as demonstrated by Bedi et al22, sutures were used to
stabilize the disc in position.
The post-operative care and constant and long-term follow-up are
very important. Although TMJ surgery aims at proper joint move-
ment and joint pain treatment, this approach often leads to muscle
atrophy. The use of physiotherapy in the post-operative period of the
surgical treatment aims to relieve pain and inflammation, decrease
swelling, promote neuromuscular re-education of masticatory mus-
cles, and prevent joint contracture and adhesion formation.1,23
Shortly after the procedure of the studied patient, the use of warm
compresses was recommended. After the release of the elastic
intermaxillary fixation, the patient was instructed to perform exer-
cises for gradual opening of the mouth and excursive movements.
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Santos et al The Journal of Craniofacial Surgery
Finally, we emphasize that physical aggressions by firearms on
the face are severe and may be associated with a variety of
complications. The initial approach should identify and address
problems that pose an immediate threat to life. Therefore, a
systematized care, following the management of life support, is
essential in patients with this lesion.
CONCLUSION
The surgical treatment for the removal of the projectile from the
inside of the TMJ accompanied by removal of bone fragments with
preservation of the articular disc resulted in the functional rehabili-
tation of the patient described in this case. Auxiliary imaging
methods such as angiography by computed tomography in the
surgical management of this case are very important, as it enabled
the evaluation of the arterial anatomy close to the foreign body. In
addition, selective embolization of the internal maxillary artery
provided a safer surgical procedure, minimizing blood loss and
allowing wide dissection for the removal of floating objects.
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