Traumatic injuries to the jaws may create facial deformities particularly involving the TMJs with unilateral or bilateral condylar or subcondylar fractures that are inadequately reduced. Patients may present with: 1) Mandible retruded or deviated toward the affected side if unilateral; 2) Pain and jaw dysfunction; 3) May exhibit deficient growth on the affected side(s) in growing patients; 4) Class II skeletal and occlusal relationships; and 5) Premature contact of the occlusion on the affected side(s) with possible open bite and on the contralateral side. Imaging features could include: 1) Evidence of previous condylar, mandibular, or mid-facial fractures; 2) The condyle, when fractured, may be mal-positioned downward, forward, and medial to the fossa; and 3) Decreased vertical ramus/condyle length. MRI will also show the disc position and condition.
At the initial presentation of the trauma, the options for treating subcondylar fractures are open reduction, closed reduction, or no treatment. The amount of displacement and the condition of the fracture(s) will dictate the necessary treatment to fix the problem. When identified early, fractures may be best treated by open reduction for significantly displaced segments or closed reduction for minimally displaced segments to achieve a symmetric face and stable occlusion. If the condyle is minimally to moderately displaced, still salvageable along with its articular disc but already healed, then it is possible that orthognathic surgery could realign the jaw structures properly, and if the disc is displaced, it can be repositioned with a Mitek anchor. If the condyle is severely deformed and non-salvageable, then the most predictable method for reconstruction of the TMJ is using custom-fitted total joint prostheses (TMJ Concepts system), TMJ fat graft, and repositioning of the mandible, if there is an associated mandibular mal-alignment. Other treatment options for TMJ reconstruction are: rib grafts, sternoclavicular grafts, etc. But these outcomes are not as predictable as a custom-fitted total joint prosthesis.