Why do I still have jaw pain 4 years after a jaw fracture?

Persistent Jaw Pain 4 Years After Jaw Fracture

You should be evaluated by an oral and maxillofacial surgeon or dentist to rule out temporomandibular joint (TMJ) involvement, chronic synovitis, malunion/nonunion of the fracture, or osteonecrosis, as these are the most common causes of persistent jaw pain years after mandibular trauma.

Primary Diagnostic Considerations

Temporomandibular Joint Disorders (TMD)

• TMD is the most common non-dental cause of facial pain, affecting 5-12% of the population, and can develop following jaw trauma 1
• TMJ synovitis presents with pain, joint tenderness, limited jaw movement, and joint sounds, with pain often localized to the TMJ area and worsening during jaw function such as chewing or speaking 2
• Long-term follow-up studies demonstrate that TMJ involvement following trauma can persist for decades, with one study showing 66.7% of patients had TMJ involvement an average of 25.8 years after initial injury 3
• MRI is the gold standard for detecting synovitis and evaluating soft tissue structures of the TMJ, while CT or CBCT is preferred for evaluating bone lesions associated with chronic synovitis 2

Fracture Complications

• Untreated or inadequately treated jaw fractures can lead to pseudoarthrosis (nonunion), which presents with pathologic mobility, persistent pain, and sometimes infection 4
• Malunion or nonunion of mandibular fractures can cause long-term disability, jaw deformity, and chronic pain that persists for years 4
• The angle of the mandible is particularly vulnerable to complications due to its lower resistance area and thinner basilar bone 5

Osteonecrosis

• Monitor for swelling of the jaw and/or jaw pain, as well as exposed mandibular bone, which may indicate osteonecrosis 1
• While medication-related osteonecrosis is more common in patients on bisphosphonates or denosumab, post-traumatic osteonecrosis can occur following fractures 1

Clinical Evaluation Algorithm

History to Obtain

• Exact location and character of pain (sharp, dull, aching, intermittent vs constant) 1
• Relationship of pain to jaw function (chewing, speaking, yawning) 2
• Presence of clicking, popping, or grinding sounds in the jaw 1
• History of how the original fracture was treated (surgical vs non-surgical, type of fixation used) 6
• Any history of infection following the original injury 4
• Presence of morning stiffness that improves with movement, which is characteristic of inflammatory joint conditions including TMJ synovitis 2

Physical Examination Findings

• Palpate the TMJ bilaterally for tenderness, as TMJ involvement may be unilateral or bilateral 2
• Assess jaw opening range and presence of deviation during opening 1
• Examine for pathologic mobility suggesting nonunion 4
• Check for exposed bone or fistulas that probe to bone 1
• Evaluate occlusion and dental alignment 1

Imaging Studies

• Obtain MRI for soft tissue evaluation if TMJ synovitis is suspected 2
• Obtain CT or CBCT to evaluate for bone complications including malunion, nonunion, or osteonecrosis 2
• Panoramic radiography can identify fracture healing status and bone abnormalities 4

Management Approach

Conservative Management (First-Line)

• Cognitive behavioral therapy (CBT) augmented with relaxation therapy or biofeedback provides the greatest pain relief for chronic TMD pain 7
• Therapist-assisted jaw mobilization and manual trigger point therapy provide substantial pain reduction 7
• Supervised jaw exercise and stretching, along with supervised postural exercise, provide important pain relief 7
• Patient education about self-management and improved self-efficacy leads to fewer symptoms 1, 7

When to Refer for Surgical Evaluation

• Refer to an oral and maxillofacial surgeon if there is evidence of pseudoarthrosis/nonunion, as surgical treatment with open reduction and internal fixation may be necessary 4
• Refer if conservative management fails after 4-6 weeks of appropriate first-line treatment 7
• Immediate referral is warranted if osteonecrosis is suspected, as this requires specialist management 1

Critical Pitfalls to Avoid

• Do not assume pain is simply "normal" after a fracture—persistent pain 4 years later warrants thorough investigation 4, 3
• Avoid prescribing occlusal splints, acetaminophen with muscle relaxants, gabapentin, benzodiazepines, or NSAIDs with opioids as first-line treatment for TMD, as these interventions lack evidence and carry significant harm risks 7
• Do not rely solely on clinical examination—imaging is essential to identify structural complications 2, 4
• Depression and catastrophizing reduce treatment success, so address psychological factors concurrently 1, 7

Prognosis Considerations

• Up to 30% of acute TMD cases may progress to chronic pain, emphasizing the importance of addressing this now rather than delaying further 7
• Untreated synovitis may lead to cartilage damage, bone erosion, and joint deformity over time 2
• The relationship between TMJ inflammation and symptoms is not always direct—some patients with significant synovitis may have minimal symptoms while others with minimal inflammation have significant pain 2