Article Type : Case Report
Authors : Shunmugavelu K
Keywords : TMJ fracture; Case report; Conservative management
Background: The treatment of TMJ fracture remains a
controversy in maxillofacial surgery. Despite mandibular fracture is a more
commonly encountered fracture it is still a debate to approach the fracture
surgical or conservative.
Case report: An interesting case of trauma on the left side
of face with TMJ fracture reported to the clinic. Proper clinical examination
and adequate investigations were done. We performed a conservative approach of
TMJ fracture management on a 41 year old patient and followed up for 6 months.
Patient had no signs of postoperative complications, patient was reviewed for 3
consecutive weeks and followed up after 6 months and found to be normal and
healthy. This is suggestive of successful management of TMJ fracture.
Conclusion: To conclude conservative management cannot be an
alternative to surgical management but in certain cases conservative management
can be administered. Case selection criteria and severity of fracture
determines the selection of treatment methods.
Maxillofacial trauma constitutes nearly 10% to 40% of the mandibular fractures [1]. Historically, temporomandibular joint fractures were conservative method with various forms of immobilization or maxillomandibular fixation, with largely favourable results [2,3]. Various complications concerning trauma affecting TMJ may be seen both in surgical and conservative management [4]. Such complications include disrupted occlusal function, internal derangement of the TMJ, facial asymmetry, nerve injury, Intra alveolar and Extra-Articular Ankylosis and limited jaw movement. The choice between two treatment modalities- surgical and controversial remains highly controversial [5]. This article aims to contribute to conservative management of TMJ fractures.
Case Report
A
41 year old male patient reported to the hospital due to trauma while working.
The patient was well built and nourished, he was conscious and well oriented to
time and place. The patient had no history of vomiting. Patient written consent
was obtained.
On examination
Temporomandibular
joint fracture is usually associated with complications. Immediate detection of
TMJ fracture and management of the above by either conservative or surgical
method can have drastic consequences in limiting complications. Clinical
features of TMJ fracture includes swelling, facial asymmetry, haemorrhage from
ear on that side, haematoma on the involved site, ecchymosis of skin just below
the mastoid process. On current visit, extra oral examination reveals left side
asymmetry face, no bleeding from ears and nose was evident. Hemotympanum and
hearing loss was not evident in this patient. There was a pre auricular
swelling with a size 3 x 3cm, soft in consistency, tender on palpation, and the
surface was warm, black blue spot suggestive of ecchymosis. Intra oral
examination revealed reduced mouth opening due to blockage of coronoid process.
Partially edentulousness in relation to 31, generalised attrition was evident,
dental caries in relation to 16, 26 and Generalised chronic periodontitis. Patient
was alright a few days after the trauma, he was conscious with pain and
swelling when brought to the hospital. Facial nerve examination was done and
was normal for the patient. No contributing past medical history and family
history was evident.
Computed tomography was done.
Figure 2: A small Radiolucency on the Temporomandibular joint suggestive of fracture in the TMJ.
Management of TMJ fractures- 2 approaches [6]
·
Conservative management with inter maxillary
mobilisation followed by functional therapy.
·
Surgical intervention to reposition and stabilize
the fragments.
Treatment
of TMJ fracture depends on various factors [7,8]
·
Physical and imaging evidence of the fracture
·
The extent of fracture (unilateral or bilateral)
·
The level of the fracture, the degree of
displacement and dislocation
·
The size and position of the fractured condylar
segment
·
The dental malocclusion and mandibular dysfunction
·
Completeness of the dentition and age of the
patient.
In
this case there was a unilateral swelling, with minimal degree of displacement,
no alteration in dental occlusion and function.
Conservative method for managing TMJ fracture
using intermaxillary fixation was done to restore the function. Conservative
approach done in the patient, prevents surgical wounds and complications due to
surgical management. This approach includes inter maxillary fixation for 3
weeks. And patient was recalled after 3 weeks and removed.
The
patient was admitted in the hospital in April 2020 with symptoms of swelling,
post auricular ecchymosis and discharged in a week. Conservative management of
the TMJ fracture was done and there were no complications and the clinical
functions were retorted back to normal. Patient was fine, happy and healthy. On
follow up after 6 months patient was found to be normal in function.
When
reporting treatment measures on human subjects, the procedures were in
accordance with the ethical standards of the responsible committee on human
experimentation and with the Helsinki Declaration the 1975, as revised in 1983.
Within
the limitations of this conservative treatment approach and investigations,
there was no signs of postoperative complications like infection, hearing loss,
nerve injury, malocclusion etc. This is suggestive of this approach being
successful in the management of TMJ fracture.
TMJ
fractures are associated with trauma due to direct hit to the side of the face.
There is a high incidence of associated hearing loss, post auricular
ecchymosis, hearing loss but facial nerve injuries and Bell’s palsy are
uncommon [5]. Timely management minimises complications. In our case, a 21 year
old had a trauma on the left side of his face. In most of the cases of the TMJ
fractures, the complications include hearing loss, facial nerve injury, in our
case, it was managed without any complications. The management of TMJ fracture
in conservative method without any complications.
TMJ
fractures involving the condyle are 19 - 52% of the craniofacial injury.
Non-surgical functional approach in unilateral TMJ fracture prevents distortion
in subsequent growth. Trauma due to direct hit is the most common cause for TMJ
fractures. High resolution CT and MRI were needed for the evaluation of the
fracture line, structure injury and complications. Most commonly TMJ fractures
are surgically managed and in our case TMJ fracture is conservatively managed
without any post treatment complications. Further patient selection criteria
and treatment guidelines must be formulated for better outcomes. Long term follow
up and more sample size comparative study with surgical management can be done.
The
author(s) declared no potential conflict of interest with respect to authorship
and/or publication of this article. No financial support was received for the
authorship and/or publication of this article.