The medico-legal evaluation of orofacial trauma encompasses clinical examination of the TMJ and individual self-reported studies [6, 5, 10,11,12, 22, 25]. TMJ diseases are identified by the WHO in the international disease coding system, namely, ICD-11, highlighting TMDs [13]. The TMD evaluation was focused on guidelines suggested by the International DC/TMD Consortium Network and Orofacial Pain Special Interest Group [12], updated in 2021 [25].

Focusing on guidelines suggested by the CEREDOC group [15], updated in 2010, TMDs are not a sequela identified in medico-legal standard evaluation; indeed, AMA guidelines, updated in 2023, also do not include TMDs as a diagnosis of medico-legal evaluation [18]. The present study emphasizes the diagnosis of TMDs in orofacial trauma, its significance as a relevant sequela, and the need for its inclusion in the reference tables. Although different organizations and jurisdictions may have their own guidelines based on cultural and socioeconomic issues, it is advisable to consult standard guidelines. Understanding the accurate methodology of TMD diagnosis is the basis for personal damage assessment, which introduces the evidential data for discussion in this scope. In the present study, the individual self-report, the selection of criteria for the clinical status (pain; jaw opening; anatomical, functional, and occlusal deficit), and their analysis were recorded with respect to injuries or temporary damage, as well as sequelae or permanent damage, in a holistic connection within the reality of medico-legal evaluation.

Giannakopoulo’s study emphasized that none of the TMJ components is exempt from injury in trauma [21], so it should be an anatomical region that is included in the clinical evaluation of the victim and examined by a health professional qualified to assess personal orofacial damage.

The present study design allowed a longitudinal evaluation of clinical status, with four evaluations impacting the rehabilitation process for personal orofacial damage. As a multifactorial disease with a traumatic etiology, a timeline series of health data records, as a set of measurements taken at intervals over time, represented a methodological procedure to identify an absolute correlation of the individual perception and the professional assessment of the clinical status. Corporal damage was evaluated as temporary in two stages of the clinical process, enabling identification and follow-up assessment of the injuries. Corporal damage as a permanent issue or impairment was assessed after the rehabilitation process as a sequela frame diagnosis. The timeline steps for clinical diagnosis after the rehabilitation process were related to the progression of TMJ pathology, following Zhang’s study [22].

In line with the literature [14, 15], the present findings emphasized the female group in TMJ trauma, according to their impact on the global frame injury context, such as increased sensitivity to pain [8].

Concerning temporary assessment in the early stages of TMJ trauma, the inflammatory stage manifests itself primarily by involving the TMJ components, uni- and/or bilaterally, influenced by the energy involved. In line with the injury frame engaging on bone components, the articular surfaces of the fibrocartilage, the articular disc, and the synovial lining of the joint space, both upper and lower [5, 21], and the role of these structures in supporting the dental arches. Psychosocial affectation can act synergistically within the complexity of orofacial trauma concerning the TMJ [5], involving pain as a transversal complaint and its impact on quality of life. The medico-legal assessment of temporary damage includes the victim’s psychosocial impact on the Quantum doloris value [16, 17]. TMJ trauma as a complex injury was carefully studied through two clinical consultations, corresponding to t1 and t2; training the victim as a coevaluator of the clinical condition through a self-questionnaire (EQ-VAS) as a quantitative measure of health outcomes provided insight into the patient’s judgment. This longitudinal analysis allowed the evaluation of the reproducibility of pain as an intangible value related to the psychological state and somatization of the victim. Functional issues associated with TMJ trauma (limitation of opening, limitation in excursive movements, deviation of the opening, and malocclusion manifesting later as a crossbite on the side of the fracture and hypereruption of the teeth on the opposite side) play a temporary role in TMJ trauma, highlighting decreased interincisal value with limited mandibular opening. Speech, chewing, and swallowing are affected [5, 18,19,20]. These diverse functions are affected by injuries to the TMJ, recorded in the early stages.

Concerning permanent assessment, the pain criterion was related to the victim’s performance in TMD assessments following DC/TMD standards, performing the PHQ-15 [12, 15, 25]. In line with Ryan’s study, a shorter questionnaire increased participation rates, and the EQ-VAS was applied for health-perception valuation in the monitoring of TMD [31]. The present study identified decreased interincisal values after rehabilitation ended, resulting in jaw-opening limitations (25 mm, minimum) based on the following TMD values in the DC/TMD standards: lower than 40 mm for adults, 38 mm for adolescents, and 36 mm for children [12, 25]. Its relation to functional issues (excursive movements) and sounds, malocclusion-engagement, and anatomic changes [4] defines the pattern of TMD and, consequently, the degree of personal damage. Furthermore, the engagement of anatomic-morphological changes in the TMJ components, supporting a higher degree of TMD damage, was identified by cone-beam computed tomography or magnetic resonance imaging [25, 26]. Documentary data are a material and legal proof for medico-legal expert reports and a tool for court declarations, in line with Honey et al. and Corte-Real et al. [28]. Data identifying degenerative TMJ components (namely, the reduction of the interline and rectification of the cortical and osteophytes) can reveal the persistence of anatomic deficits. The findings of anatomical changes, either dental or bone-related or both (5% or 20%, respectively), showed the impact on facial harmony that resulted in a disharmony status. The anatomical changes between the right and left sides, leading to facial asymmetry, impact the medico-legal evaluation of aesthetic damage [17, 19]. Such is emphasized when the trauma occurs in the early stages of individual development, i.e., under the age of 8 years, increasing the damage degree. In the rehabilitation process, the dental prosthetic procedure allows the recovery of dental loss and occlusal function, and it justifies overcoming the dental anatomy deficit. Nevertheless, the occlusal deficit recorded in all the victims was not overcome in 40% of cases, and this could correspond to prosthetic and rehabilitation failure [26]. The occlusal deficit should be evaluated in the TMD diagnosis as either a synergic factor exacerbating the symptoms or a nonrelated feature in TMD pathogenesis [20].

TMJ trauma is extraordinarily complex and impacts the victim’s life, following the global trend to consider TMD as a chronic disease [5, 6, 12, 25, 29,30,31]. As stated in Gençosmanoğlu’s study, an inappropriate anatomical position in which body structures or segments increase the TMJ load and energy consumption may cause TMD [31]. The originally proposed segmentation of the clinical criteria into three degrees (I to II) allowed future studies on TMD damage categorization and its correspondence with the impairment value of corporal damage. This musculoskeletal disorder engages the individual in a biosocial-psychological context that interacts with risk factors, including depressive and parafunctional disorders, creating a perfect storm in younger people aged 10 to 49 years [2, 12]. In addition, health quality scales, such as EQ-VAS, coengage the victim’s impact as a sequela affecting his or her health quality. Future studies on this topic are needed to present evidence data to the scientific community.

The mandibular dysfunction designation reported in the European reference table corresponds in the reference table to an extensive value of permanent damage, ranging from 6 to 30 points (corresponding to the lower open mouth value, mandibular dysfunction). The expert needs concrete guidance for standardized performance. There needs to be more consistency in the expert assessment, jeopardizing the role of references in the application and orientation of a reference table. TMJ trauma, namely, TMDs, should not be ignored in the clinical analysis of the medico-legal evaluation of orofacial trauma; such trauma must be the object of a critical, reasonable, and experienced medico-legal evaluation. The reference guidelines should consider TMD diagnosis based on the objective criteria presented in this study and should be revised to account for real corporal damage in the medico-legal evaluation of an orofacial trauma scenario.