Copyright © 2019 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited. Surgical Management of Gunshot Injury to the Temporomandibular Joint Marcelo Soares dos Santos, DDS,  Kalyne Kelly Negromonte Gonc ¸alves, DDS, y Caio Ce ´sar Gonc ¸alves Silva, DDS,  Demo ´stenes Alves Diniz, DDS, y and Belmiro Cavalcanti do Egito Vasconcelos, DDS, PhD z Abstract: One of the indications of the surgical approach of the 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 Clark et al 3 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 Restaurac ¸a ˜o, 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 From the  Department of Oral and Maxillofacial Surgery, School of Dentistry, Universidade de Pernambuco, Camaragibe; y Service of Oral and Maxillofacial Surgery; and z Department of Oral and Maxillofacial Surgery, School of Dentistry, Universidade de Pernambuco, and Staff of the Oral and Maxillofacial Surgery service, Hospital da Restaurac ¸a ˜o, 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 CLINICAL STUDIY The Journal of Craniofacial Surgery  Volume 30, Number 7, October 2019 2257