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Mandibular Condyle Reconstruction With Inlay Application of Autogenous Costochondral Graft After Condylectomy: Cerrahpaşa’s Technique
J Oral Maxillofac Surg 65:615-620, 2007
Mandibular Condyle Reconstruction With Inlay Application of Autogenous Costochondral Graft After Condylectomy: Cerrahpas¸a’s Technique M. Zeki Güzel, MD,* Hakan Arslan, MD,† and Mesut Saraç, MD‡ Purpose: Mandibular condyle reconstruction with free costochondral grafting is the most common
method because of some advantages, such as its biological and anatomic similarities to the condyle, and growth potential in juveniles. Application techniques of the costochondral graft were reported in numerous articles with several advantages and disadvantages up to now. The purpose of this article is to present a new modification in application of the costochondral graft to the ramus of the mandible. This technique is pretty simple, but very effective. Materials and Methods: The new technique described here consisted of a costochondral graft application for temporomandibular joint reconstruction, which was inserted into the medullary cavity of the mandibular ramus in 4 patients. This modification provided the graft placement as anatomical as the original condyle and further stabilized the graft in its position and inhibited its displacement without any fixation. This technique is pretty simple because an additional incision to the preauricular, facial nerve dissection, wide exposition and stabilization efforts are not required. Results: Clinical and radiological evaluations on 14-month mean follow-up of 4 cases showed very satisfactory functional results with normal anatomic adaptation and configuration. In all cases, function of mandible was considered to be good with at least maximal interincisal opening of 30 mm. Good anatomical position of the graft and good bony healing were seen on the radiographs. Additionally, there was no need for postoperative intermaxillary fixation. Conclusion: With this technique, temporomandibular joint reconstruction by the costochondral graft can be performed as far as possible to the original condyle position. © 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:615-620, 2007 The indications for temporomandibular joint (TMJ) reconstruction are well-established and include ankylosis, severe osteoarthritis, rheumatoid arthropathy,
neoplastic disease, post-traumatic dysfunction, and congenital disease.1,2 The aims of reconstruction include the restoration of mandibular function and form, decreased patient disability and suffering, and the prevention of disease progression.3 The method of reconstruction, however, is controversial and a multitude of techniques both autogenous (fibula, metatarsal, clavicle, iliac, and costochondral) and alloplastic (acrylic, synthetic fibers, ulnar head prosthesis, compressible silicone rubber, and total joint systems) have been described.4-6 The autogenous technique accepted most widely involves the costochondral graft. The advantages of this graft are its biologic compatibility, workability, functional adaptability, and minimal additional detriment to the patient.7 The growth potential of the costochondral graft makes it the ideal choice in children.8,9
*Professor and Chairman, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey. †Registrar, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey. ‡Plastic Surgeon, Private Practice, Istanbul, Turkey. Address correspondence and reprint requests to Dr Güzel: I.U. Cerrahpas¸a Medical Faculty, Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpas¸a Medical Faculty Hospital, 34303 Istanbul, Turkey; e-mail: [email protected] © 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6504-0004$32.00/0 doi:10.1016/j.joms.2005.12.061
615
616
TMJ RECONSTRUCTION
Table 1. CLINICAL FINDINGS OF CASES
No.
Age (yrs)
Gender
Clinical Characteristic
Aetiology
1
10
M
Facial trauma after car accident at the age of 5
2
46
F
3
17
M
4
35
F
5 mm of mouth opening Deviated dental mid-line Unilateral TMJ ankylosis 19 mm of mouth opening Unilateral 2 to 3 mm of mouth opening Retrognathia/anterior open bite Bilateral TMJ ankylosis Negative overbite that lower incisors overlap the lower ones with 0 mm of mouth opening Unilateral TMJ ankylosis
Tumor on the left condyle Facial trauma after car accident at the age of 6 Facial trauma
Abbreviations: F, female; M, male; TMJ, temporomandibular joint. Güzel, Saraç, and Arslan. TMJ Reconstruction. J Oral Maxillofac Surg 2007.
Potential problems with the costochondral graft include fracture, further ankylosis, donor site morbidity, and the variable growth behavior of the graft.10 The surgical technique for application of costochondral graft to the ramus of the mandible after condylectomy has been well described.2,7,11-18 Access is by preauricular and lower border incisions to use the wires, screws, or plates for the fixation of the graft. The latter incision is just below the lower border of the mandible and the dissection that is required to identify the marginal mandibular branch of the facial nerve has a potential risk for the injury of the nerve. The purpose of this study is to present a new modification in the application of the costochondral graft to the ramus of the mandible. This technique is simple, but effective.
Methods and Materials Three male patients with TMJ ankylosis and 1 female patient with a tumor underwent 5 inlay costochondral graft applications between 2001 and 2004 at the Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University, Cerrahapas¸a Medical Faculty, Istanbul, Turkey (Table 1). Ankylosis occurred bilaterally in 1 case, and unilaterally in 2 cases. In the bilateral TMJ ankylosis case, clinical findings included micrognathia and anterior open bite, whereas in cases of unilateral TMJ ankylosis, deviation of the mandible to the affected side and facial asymmetry were present. In the tumor case, laterognathia and prognathia with restricted mouth opening were present. SURGICAL TECHNIQUE
All patients were operated on under general anesthesia using nasal fiberoptic intubation. Skin preauric-
ular incision extending to the temporal region, curving backward and upward, posterior of the main branches of the temporal vessels was carried out. The incision was carried through the subcutaneous tissue, the superficial temporalis fascia. Blunt dissection was carried out downward, to a point 2 cm above the zygomatic arch where the deep temporalis fascia splits into 2 layers containing fatty issue. The periosteum was incised on the most posterior aspect of the arch and this flap, including the zygomatic and temporal branches of the facial nerve, was retracted forward under the periosteum. Dissection was continued downward to the subcondylar region subperiosteally. The ankylotic mass was resected radically at the subcondylar region to create an approximately 8 to 10 mm gap, with an electrical saw initially and completed with chisel until movement of the mandible was noted (Figs 1A,B). A 50-mm costochondral graft including about 15 mm of cartilage was harvested from the ninth or tenth rib. A cavity was created by a burr in the ramus, leaving only a 1.5 to 2 mm peripheral cortical bone around the stump (Figs 1C,D). The depth and the size of the tunnel created in the ramus was designed according to the graft; the depth of the tunnel was carved as deep as two thirds of the length of the costochondral graft that was approximately 25 to 30 mm in our cases. Excavation of the ramus as long as 15 mm can also be adequate. The remaining one third of the graft that consists of mainly a cartilaginous part and an osseous component was placed outside of the tunnel. The width of the tunnel was adjusted exactly the same or a bit smaller than the graft. The bony segment of the graft was rounded slightly for a tight fit and the cartilaginous end was reduced to 4 to 5 mm to conform to the glenoid fossa. In this manner, when the graft is inserted into the cavity, it cannot move easily in any direction even without any fixation (Figs 1E,F). Although there was no need to fix the grafts in all cases,
617
GÜZEL, SARAÇ, AND ARSLAN
structed to increase the use of the jaw. Exercises were gradually intensified, and protrusive and lateral movements were added later. Progress was evaluated by means of a ruler. No apparatus or exercise device for passive mobilization was used.
Report of Cases CASE 1
FIGURE 1. Operative technique. A, Intraoperative photograph showing condylectomy with saw and chisel. B, Intraoperative photograph showing about 10 mm gap after condylectomy (black arrow). C, Intraoperative photograph showing a socket created in ramus of mandible. D, Corresponding schematic drawing. E, Intraoperative photograph showing inlay adaptation of the costochondral graft (black arrow). F, Corresponding schematic drawing. Güzel, Saraç, and Arslan. TMJ Reconstruction. J Oral Maxillofac Surg 2007.
we preferred to use 1 screw with a washer in the first case, and 1 screw in the second case for additional stabilization in terms of security. After these experiences, in the last case that was reconstructed bilaterally, we did not use any screw-plate fixation systems. We did not use any interpositional autogenous tissue or alloplastic material between the glenoid fossa and cartilage end of the graft. Intermaxillary fixation was only applied intraoperatively to determine the graft position and to facilitate the trimming. Postoperative maxillomandibular immobilization was not used in any cases, but patients were in-
A 10-year-old male presented with right high subcondylar and right zygomatic fractures after a road traffic accident at the age of 5 years. The fractures were untreated and mouth opening decreased with time. At the time of presentation, maximal interincisal opening was 5 mm (Fig 2A). Radiologic examination showed complete bony ankylosis, extending mainly medially on the right TMJ (Fig 2B). Using only a preauricular incision, a gap was produced below the ankylosed segment at the level of the condylar neck with an electrical saw and osteotome. There were no meniscal remnants. A costochondral graft 50 mm in length including 20 mm of cartilage was then harvested from the ninth rib. After the graft was inserted according to the technique mentioned above, graft stabilization was achieved perfectly. In terms of security, 1 screw and a washer, which was custom-made from the single hole of the miniplate, were used to fix the costochondral graft. One month after surgery, the maximal interincisal opening was 30 mm. It remains unchanged (3-years postoperatively) with acceptable facial symmetry (Fig 2C). Occlusal canting and dental midline relationship
FIGURE 2. Case 1. A, Male child with multiple scars on the right cheek subsequent to a traffic accident, limited mouth opening, and marked deviation of the dental midline. B, Computed tomography section in the axial plane showing the major part of the ankylotic mass extends medially. C, View of the patient showing 30 mm mouth opening 1-year postoperatively. D, One-year postoperative photograph of the patient, showing near normal occlusion. E,F, Three-year postoperative radiographic appearance. The graft in normal anatomic position incorporated perfectly into the ascending ramus.
FIGURE 3. Case 2. A, Female referred with a slowly growing tumor in the left preauricular region. B,C, Orthopantomogram and computed tomography section in the frontal plane, showing a expansile and lytic tumor in her left condyle and obliteration of the joint space. D, View of the patient, showing 40 mm mouth opening 1 year postoperatively. E, One-year postoperative photograph of the patient, showing near normal occlusion. F, Radiographic appearance 1 year later. The graft in normal anatomic position incorporated perfectly into the ascending ramus.
Güzel, Saraç, and Arslan. TMJ Reconstruction. J Oral Maxillofac Surg 2007.
Güzel, Saraç, and Arslan. TMJ Reconstruction. J Oral Maxillofac Surg 2007.
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TMJ RECONSTRUCTION
also was corrected and near normal occlusion was achieved (Fig 2D). Panoramic view and computed tomography (CT) of the mandible showed a totally remodeled condyle on the right side and the distance between the glenoid fossa and bony rib-end was the same as the nonaffected side (Figs 2E,F). CASE 2
A 46-year-old female, who was referred with a rapidly growing tumor in the left preauricular region, had complained of pain in the left TMJ and a progressive limitation of opening of the mouth. At the time of presentation, maximal interincisal opening was 19 mm, and lack of mandibular function, chin deviation, prognathism, and facial asymmetry were evident (Fig 3A). Radiographic examination showed an expansive and lytic bone process in the left condyle (Figs 3B,C). Via only a preauricular approach, an extracapsular resection of the tumor with a part of the ramus was carried out (odontogenic fibromyxoma was the result of histopathologic examination). A costochondral graft of appropriate length was inserted into the prepared tunnel in the ramus according to the technique mentioned above. Although stabilization of the graft was achieved perfectly, fixation with only 1 screw was applied for additional security. One month after surgery, the maximal interincisal opening was 40 mm. The dental midline relationship also was corrected and near normal occlusion was achieved with her old prosthesis and is currently unchanged (1-year postoperatively) with acceptable facial symmetry (Figs 3D,E). Panoramic view of the mandible showed a totally remodeled condyle on the left side (Fig 3F). CASE 3
A 17-year-old male was involved in a road traffic accident at the age of 6 years. At the time of the injury, he sustained a right subcondylar fracture with marked lateral displacement of the head of the condyle, left subcondylar fracture with minimal anterior displacement of the head of the condyle, and right paramedian fracture of the mandible. He was treated elsewhere by open reduction and a wire osteosynthesis across the paramedian mandible fracture. He complained of pain in the TMJ bilaterally and a progressive limitation of opening of the mouth. At the time of presentation, maximal interincisal opening was 2 to 3 mm, and bilateral ankylosis, canting of the occlusal plan, retrognathism, open bite, and facial asymmetry were present (Fig 4A). Radiologic examination showed complete bony ankylosis including the coronoid process (Figs 4B,C). Via only a preauricular approach, the ankylotic mass with coronoid process were resected radically on the right side and resection of the condyle was carried out on the left side to create an
FIGURE 4. Case 3. A, Male child who was involved in a road traffic accident, had limited mouth opening, open bite, and severe deviation of the dental midline. B, Orthopantomogram, showing undefined TMJ with a gross ankylotic mass on the right side. C, Computed tomography section in the frontal plane, showing complete loss of the right joint space caused by bony ankylotic mass (black arrow), extended mainly medially and narrowing in the left joint space. D, View of the patient showing 35 mm mouth opening 8 months postoperatively. E,F, Eightmonth postoperative radiographic appearance (computed tomography and panoramic) showing the grafts without fixation in normal anatomic position incorporated perfectly into the ascending ramus bilaterally (artifacts on the right side are belong to vascular clips). Güzel, Saraç, and Arslan. TMJ Reconstruction. J Oral Maxillofac Surg 2007.
approximately 10 mm gap bilaterally. Costochondral grafts were tightly inserted into the prepared tunnels in the ascending ramus bilaterally. No fixation to the graft was applied. One month after surgery, the maximal interincisal opening was 35 mm. It remains unchanged (8-months postoperatively) (Fig 4D). Panoramic view and CT of the mandible showed totally remodeled condyles in both side and the distance between the glenoid fossa and bony rib-end were normal bilaterally (Figs 4E,F).
Discussion Costochondral grafts have been used for reconstruction of the TMJ relating to ankylosis, post-traumatic dysfunction, facial asymmetry, neoplastic disease, osteoarthritis, and rheumatoid arthritis.18,19 The goals of TMJ arthroplasty are not only rehabilitation of the complex mechanism of the normal joint, but also restoration of facial skeletal symmetry, occlusal disharmony, and mastication.11 Kaban et al1 recommended costochondral grafts for surgical reconstruction of the TMJ after reporting the advantages and disadvantages of many other techniques. Ostectomy alone gives rise to a gap between the articular cavity and the mandibular ramus and has the disadvantage of generating a pseudo-articulation, with shortening of the mandibular ramus. In addition, it seems to increase the risk of recurrence. Complications such as
619
GÜZEL, SARAÇ, AND ARSLAN
the development of an open bite in bilateral cases, premature occlusion on the affected side with contralateral open bite in unilateral cases, and limited mouth opening postoperatively are possible in such gap arthroplasty. Interposition of autogenous or alloplastic material in the ostectomy site is a mechanism to prevent recurrence, however, there are possible disadvantages,1 including morbidity at the donor site and unpredictable resorption when autogenous material is used, and risk of a foreign body reaction when alloplastic material is used. Use of autogenous materials (costochondral graft, clavicular graft, iliac crest, metatarsus) requires a longer surgical time, and presents risk of morbidity of the donor site.1 The costochondral graft has advantages, however, including biocompatibility, adaptation of the graft to the articular fossa, and potential growth. The autogenous costochondral graft has been considered the most acceptable tissue for reconstruction of the TMJ because of anatomic similarity to the mandibular condyle. However, absence of predictability of the amount of costochondral graft growth and other unusual complications20 have been reported by some authors8,21-23 as disadvantages of the technique. Several authors1,24-28 have reported the combined use of the preauricular and submandibular Risdon’s incisions. These allow adequate visualization of the surgical field, and allow fixation of the costochondral graft that is usually attached to the posterior or the posterolateral border of the ramus of the mandible. However, even with a precise dissection and identification of the mandibular branch of the facial nerve, there remains a potential risk for nerve injury. Fixation with plate screws, several screws, or with a simple wire of the graft to the ramus of the mandible is always necessary and these procedures have some difficulties on practice. The costochondral graft cannot be oriented usually in the anatomic position of the original condyle. In addition, a submandibular incision usually produces a visible scar on the face. The technique discussed in this study has the following advantages: 1) 1 incision (preauricular incision) is sufficient; 2) exposure during the preparation of the recipient bed and application of the graft is easy and has a minimal risk of facial nerve injury because exposure of the whole lateral aspect of the mandibular ramus is not required; 3) the graft can be placed in an anatomic position; for this reason, the graft can be incorporated well into the ascending ramus; 4) although any fixation for stabilization of the graft may not be required, there can be a single screw via a preauricular incision applied easily when a perfect stabilization is desired, in terms of additional security; and 5) there is a complete bone-to-bone contact between the ramus of mandible and the bone
part of the costochondral graft that can provide good bone healing. The new technique described consisted of a costochondral graft application for the TMJ reconstruction that was inserted into the medullary cavity of the mandibular ramus. This modification further stabilized the graft in its position and inhibited its displacement without any fixation. There are some limitations of this technique, including congenital absence of the TMJ (ie, hemifacial microsomia), in which the absence of any ascending ramus would make a second incision necessary. With congenital aplasia, and sometimes with normal mandibles, the width of the ascending ramus will be too narrow to permit the use of an inlay technique. We suggest this technique is best suited for the acquired diseases of the TMJ where the size of the ramus is sufficient. The complication of facial nerve weakness occurs when there is excessive retraction intraoperatively. This usually responds to steroid therapy, and function is regained when the inflammation subsides in 4 to 6 weeks. We used the modified preauricular incision described by Al-kayat and Bramley29 in our patients and perhaps, due to the fact that exposure of the whole lateral aspect of mandibular ramus was not required, we did not see any immediate postoperative facial nerve weakness.
References 1. Kaban LB, Perrott D, Fisher K: A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 48: 1145, 1990 2. Lindqvist C, Jokinen J, Paukku P, et al: Adaptation of autogenous costochondral grafts used for temporomandibular joint reconstruction: A long term clinical and radiologic follow up. J Oral Maxillofac Surg 46:465, 1988 3. Mercuri LG: The use of alloplastic prostheses for temporomandibular joint reconstruction. J Oral Maxillofac Surg 58:70, 2000 4. Cope MR, Moos KF, Hammersley N: The compressible silicone rubber prosthesis in temporomandibular joint disease. Br J Oral Maxillofac Surg 31:376, 1993 5. Hensher R: Temporomandibular joint replacement. Br J Hosp Med 53:455, 1995 6. Kent JN, Misiek DJ: Controversies in disc and condyle replacement for partial and total temporomandibular joint reconstruction, in Worthington P, Evans JR (eds): Controversies in Oral and Maxillofacial Surgery. Philadelphia, WB Saunders, 1994, pp 397-435 7. MacIntosh RB: Costochondral grafts, in Bell WH (ed): Modern Practice in Orthognathic Surgery. Philadelphia, WB Saunders, 1992, p 872 8. Figueroa AA, Gans BJ, Pruzansky S: Long term follow-up of a mandibular costochondral graft. Oral Surg Oral Med Oral Pathol 58:257, 1984 9. Wen-Ching Ko E, Huang CS, Chen YR: Temporomandibular joint reconstruction in children using costochondral grafts. J Oral Maxillofac Surg 57:789, 1999 10. Link JO, Hoffman DC, Laskin DM: Hyperplasia of a costochondral graft in an adult. J Oral Maxillofac Surg 51:1392, 1993 11. Lindqvist C, Pihakari A, Tasanen A, et al: Autogenous costochondral grafts in temporo-mandibular joint arthroplasty. A survey of 66 arthroplasties in 60 patients. J Maxillofac Surg 14:143, 1986
620 12. Matsuura H, Miyamoto H, Ishimaru JI, et al: Costochondral grafts in reconstruction of the temporomandibular joint after condylectomy: An experimental study in sheep. Br J Oral Maxillofac Surg 39:189, 2001. 13. Obeid G, Guttenberg SA, Connole PW: Costochondral grafting in condylar replacement and mandibular reconstruction. J Oral Maxillofac Surg 46:177, 1988 14. Peltomaki T: Growth of a costochondral graft in the rat temporomandibular joint. J Oral Maxillofac Surg 50:851, 1992 15. Politis C, Fossion E, Bossuyt M: The use of costochondral grafts in arthroplasty of the temporomandibular joint. J Craniomaxillofac Surg 15:345, 1987 16. Rowe NL: Ankylosis of the temporomandibular joint. Part 2. J R Coll Surg Edinb 27:167, 1982 17. Rowe NL: Ankylosis of the temporomandibular joint. Part 3. J R Coll Surg Edinb 27:209, 1982 18. Saeed NR, Hensher R, McLeod NMH, et al: Reconstruction of the temporomandibular joint autogenous compared with alloplastic. Br J Oral Maxillofac Surg 40:296, 2002 19. Ware WH, Brown SL: Growth center transplantation on replace mandibular condyle. J Maxillofac Surg 9:50, 1981 20. Merkx MAW, Freihofer HPM: Fracture of costochondral graft in temporomandibular joint reconstructive surgery: An unexpected complication. Int J Oral Maxillofac Surg 24:142, 1995
TMJ RECONSTRUCTION 21. Faerber TH, Ennis RL, Allen GA: Temporomandibular joint ankylosis following mastoiditis: Report of a case. J Oral Maxillofac Surg 48:866, 1990 22. Kent JN, Misiek DJ, Akin RK, et al: Temporomandibular joint condylar prosthesis: A ten-year report. J Oral Maxillofac Surg 41:245, 1983 23. Lata J, Kapila BK: Overgrowth of a costochondral graft in temporomandibular joint reconstructive surgery: An uncommon complication. Quintessence Int 31:412, 2000 24. Boon LC, Nik-Hussein NN: Management of ankylosed temporomandibular joint in a young child. J Pedod 14:136, 1990 25. Guyuron B, Lasa CT: Unpredictable growth pattern of costochondral graft. Plast Reconstr Surg 90:880, 1992 26. Hall MB, Brown RW, Lebowitz MS: Facial nerve injury during surgery of the temporomandibular joint: A comparison of two dissection techniques. J Oral Maxillofac Surg 43:20, 1995 27. MacIntosh RB, Henny FA: A spectrum costochondral grafts. J Maxillofac Surg 5:257, 1977 28. Mosby EL, Hiatt R: A technique of fixation of costochondral grafts for reconstruction of the temporomandibular joint. J Oral Maxillofac Surg 47:209, 1989 29. Al-Kayat A, Bramley P: A modified preauricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 17:91, 1979
Mandibular Condyle Reconstruction With Inlay Application of Autogenous Costochondral Graft After Condylectomy: Cerrahpas¸a’s Technique M. Zeki Güzel, MD,* Hakan Arslan, MD,† and Mesut Saraç, MD‡ Purpose: Mandibular condyle reconstruction with free costochondral grafting is the most common
method because of some advantages, such as its biological and anatomic similarities to the condyle, and growth potential in juveniles. Application techniques of the costochondral graft were reported in numerous articles with several advantages and disadvantages up to now. The purpose of this article is to present a new modification in application of the costochondral graft to the ramus of the mandible. This technique is pretty simple, but very effective. Materials and Methods: The new technique described here consisted of a costochondral graft application for temporomandibular joint reconstruction, which was inserted into the medullary cavity of the mandibular ramus in 4 patients. This modification provided the graft placement as anatomical as the original condyle and further stabilized the graft in its position and inhibited its displacement without any fixation. This technique is pretty simple because an additional incision to the preauricular, facial nerve dissection, wide exposition and stabilization efforts are not required. Results: Clinical and radiological evaluations on 14-month mean follow-up of 4 cases showed very satisfactory functional results with normal anatomic adaptation and configuration. In all cases, function of mandible was considered to be good with at least maximal interincisal opening of 30 mm. Good anatomical position of the graft and good bony healing were seen on the radiographs. Additionally, there was no need for postoperative intermaxillary fixation. Conclusion: With this technique, temporomandibular joint reconstruction by the costochondral graft can be performed as far as possible to the original condyle position. © 2007 American Association of Oral and Maxillofacial Surgeons J Oral Maxillofac Surg 65:615-620, 2007 The indications for temporomandibular joint (TMJ) reconstruction are well-established and include ankylosis, severe osteoarthritis, rheumatoid arthropathy,
neoplastic disease, post-traumatic dysfunction, and congenital disease.1,2 The aims of reconstruction include the restoration of mandibular function and form, decreased patient disability and suffering, and the prevention of disease progression.3 The method of reconstruction, however, is controversial and a multitude of techniques both autogenous (fibula, metatarsal, clavicle, iliac, and costochondral) and alloplastic (acrylic, synthetic fibers, ulnar head prosthesis, compressible silicone rubber, and total joint systems) have been described.4-6 The autogenous technique accepted most widely involves the costochondral graft. The advantages of this graft are its biologic compatibility, workability, functional adaptability, and minimal additional detriment to the patient.7 The growth potential of the costochondral graft makes it the ideal choice in children.8,9
*Professor and Chairman, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey. †Registrar, Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey. ‡Plastic Surgeon, Private Practice, Istanbul, Turkey. Address correspondence and reprint requests to Dr Güzel: I.U. Cerrahpas¸a Medical Faculty, Department of Plastic, Reconstructive and Aesthetic Surgery, Cerrahpas¸a Medical Faculty Hospital, 34303 Istanbul, Turkey; e-mail: [email protected] © 2007 American Association of Oral and Maxillofacial Surgeons
0278-2391/07/6504-0004$32.00/0 doi:10.1016/j.joms.2005.12.061
615
616
TMJ RECONSTRUCTION
Table 1. CLINICAL FINDINGS OF CASES
No.
Age (yrs)
Gender
Clinical Characteristic
Aetiology
1
10
M
Facial trauma after car accident at the age of 5
2
46
F
3
17
M
4
35
F
5 mm of mouth opening Deviated dental mid-line Unilateral TMJ ankylosis 19 mm of mouth opening Unilateral 2 to 3 mm of mouth opening Retrognathia/anterior open bite Bilateral TMJ ankylosis Negative overbite that lower incisors overlap the lower ones with 0 mm of mouth opening Unilateral TMJ ankylosis
Tumor on the left condyle Facial trauma after car accident at the age of 6 Facial trauma
Abbreviations: F, female; M, male; TMJ, temporomandibular joint. Güzel, Saraç, and Arslan. TMJ Reconstruction. J Oral Maxillofac Surg 2007.
Potential problems with the costochondral graft include fracture, further ankylosis, donor site morbidity, and the variable growth behavior of the graft.10 The surgical technique for application of costochondral graft to the ramus of the mandible after condylectomy has been well described.2,7,11-18 Access is by preauricular and lower border incisions to use the wires, screws, or plates for the fixation of the graft. The latter incision is just below the lower border of the mandible and the dissection that is required to identify the marginal mandibular branch of the facial nerve has a potential risk for the injury of the nerve. The purpose of this study is to present a new modification in the application of the costochondral graft to the ramus of the mandible. This technique is simple, but effective.
Methods and Materials Three male patients with TMJ ankylosis and 1 female patient with a tumor underwent 5 inlay costochondral graft applications between 2001 and 2004 at the Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University, Cerrahapas¸a Medical Faculty, Istanbul, Turkey (Table 1). Ankylosis occurred bilaterally in 1 case, and unilaterally in 2 cases. In the bilateral TMJ ankylosis case, clinical findings included micrognathia and anterior open bite, whereas in cases of unilateral TMJ ankylosis, deviation of the mandible to the affected side and facial asymmetry were present. In the tumor case, laterognathia and prognathia with restricted mouth opening were present. SURGICAL TECHNIQUE
All patients were operated on under general anesthesia using nasal fiberoptic intubation. Skin preauric-
ular incision extending to the temporal region, curving backward and upward, posterior of the main branches of the temporal vessels was carried out. The incision was carried through the subcutaneous tissue, the superficial temporalis fascia. Blunt dissection was carried out downward, to a point 2 cm above the zygomatic arch where the deep temporalis fascia splits into 2 layers containing fatty issue. The periosteum was incised on the most posterior aspect of the arch and this flap, including the zygomatic and temporal branches of the facial nerve, was retracted forward under the periosteum. Dissection was continued downward to the subcondylar region subperiosteally. The ankylotic mass was resected radically at the subcondylar region to create an approximately 8 to 10 mm gap, with an electrical saw initially and completed with chisel until movement of the mandible was noted (Figs 1A,B). A 50-mm costochondral graft including about 15 mm of cartilage was harvested from the ninth or tenth rib. A cavity was created by a burr in the ramus, leaving only a 1.5 to 2 mm peripheral cortical bone around the stump (Figs 1C,D). The depth and the size of the tunnel created in the ramus was designed according to the graft; the depth of the tunnel was carved as deep as two thirds of the length of the costochondral graft that was approximately 25 to 30 mm in our cases. Excavation of the ramus as long as 15 mm can also be adequate. The remaining one third of the graft that consists of mainly a cartilaginous part and an osseous component was placed outside of the tunnel. The width of the tunnel was adjusted exactly the same or a bit smaller than the graft. The bony segment of the graft was rounded slightly for a tight fit and the cartilaginous end was reduced to 4 to 5 mm to conform to the glenoid fossa. In this manner, when the graft is inserted into the cavity, it cannot move easily in any direction even without any fixation (Figs 1E,F). Although there was no need to fix the grafts in all cases,
617
GÜZEL, SARAÇ, AND ARSLAN
structed to increase the use of the jaw. Exercises were gradually intensified, and protrusive and lateral movements were added later. Progress was evaluated by means of a ruler. No apparatus or exercise device for passive mobilization was used.
Report of Cases CASE 1
FIGURE 1. Operative technique. A, Intraoperative photograph showing condylectomy with saw and chisel. B, Intraoperative photograph showing about 10 mm gap after condylectomy (black arrow). C, Intraoperative photograph showing a socket created in ramus of mandible. D, Corresponding schematic drawing. E, Intraoperative photograph showing inlay adaptation of the costochondral graft (black arrow). F, Corresponding schematic drawing. Güzel, Saraç, and Arslan. TMJ Reconstruction. J Oral Maxillofac Surg 2007.
we preferred to use 1 screw with a washer in the first case, and 1 screw in the second case for additional stabilization in terms of security. After these experiences, in the last case that was reconstructed bilaterally, we did not use any screw-plate fixation systems. We did not use any interpositional autogenous tissue or alloplastic material between the glenoid fossa and cartilage end of the graft. Intermaxillary fixation was only applied intraoperatively to determine the graft position and to facilitate the trimming. Postoperative maxillomandibular immobilization was not used in any cases, but patients were in-
A 10-year-old male presented with right high subcondylar and right zygomatic fractures after a road traffic accident at the age of 5 years. The fractures were untreated and mouth opening decreased with time. At the time of presentation, maximal interincisal opening was 5 mm (Fig 2A). Radiologic examination showed complete bony ankylosis, extending mainly medially on the right TMJ (Fig 2B). Using only a preauricular incision, a gap was produced below the ankylosed segment at the level of the condylar neck with an electrical saw and osteotome. There were no meniscal remnants. A costochondral graft 50 mm in length including 20 mm of cartilage was then harvested from the ninth rib. After the graft was inserted according to the technique mentioned above, graft stabilization was achieved perfectly. In terms of security, 1 screw and a washer, which was custom-made from the single hole of the miniplate, were used to fix the costochondral graft. One month after surgery, the maximal interincisal opening was 30 mm. It remains unchanged (3-years postoperatively) with acceptable facial symmetry (Fig 2C). Occlusal canting and dental midline relationship
FIGURE 2. Case 1. A, Male child with multiple scars on the right cheek subsequent to a traffic accident, limited mouth opening, and marked deviation of the dental midline. B, Computed tomography section in the axial plane showing the major part of the ankylotic mass extends medially. C, View of the patient showing 30 mm mouth opening 1-year postoperatively. D, One-year postoperative photograph of the patient, showing near normal occlusion. E,F, Three-year postoperative radiographic appearance. The graft in normal anatomic position incorporated perfectly into the ascending ramus.
FIGURE 3. Case 2. A, Female referred with a slowly growing tumor in the left preauricular region. B,C, Orthopantomogram and computed tomography section in the frontal plane, showing a expansile and lytic tumor in her left condyle and obliteration of the joint space. D, View of the patient, showing 40 mm mouth opening 1 year postoperatively. E, One-year postoperative photograph of the patient, showing near normal occlusion. F, Radiographic appearance 1 year later. The graft in normal anatomic position incorporated perfectly into the ascending ramus.
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also was corrected and near normal occlusion was achieved (Fig 2D). Panoramic view and computed tomography (CT) of the mandible showed a totally remodeled condyle on the right side and the distance between the glenoid fossa and bony rib-end was the same as the nonaffected side (Figs 2E,F). CASE 2
A 46-year-old female, who was referred with a rapidly growing tumor in the left preauricular region, had complained of pain in the left TMJ and a progressive limitation of opening of the mouth. At the time of presentation, maximal interincisal opening was 19 mm, and lack of mandibular function, chin deviation, prognathism, and facial asymmetry were evident (Fig 3A). Radiographic examination showed an expansive and lytic bone process in the left condyle (Figs 3B,C). Via only a preauricular approach, an extracapsular resection of the tumor with a part of the ramus was carried out (odontogenic fibromyxoma was the result of histopathologic examination). A costochondral graft of appropriate length was inserted into the prepared tunnel in the ramus according to the technique mentioned above. Although stabilization of the graft was achieved perfectly, fixation with only 1 screw was applied for additional security. One month after surgery, the maximal interincisal opening was 40 mm. The dental midline relationship also was corrected and near normal occlusion was achieved with her old prosthesis and is currently unchanged (1-year postoperatively) with acceptable facial symmetry (Figs 3D,E). Panoramic view of the mandible showed a totally remodeled condyle on the left side (Fig 3F). CASE 3
A 17-year-old male was involved in a road traffic accident at the age of 6 years. At the time of the injury, he sustained a right subcondylar fracture with marked lateral displacement of the head of the condyle, left subcondylar fracture with minimal anterior displacement of the head of the condyle, and right paramedian fracture of the mandible. He was treated elsewhere by open reduction and a wire osteosynthesis across the paramedian mandible fracture. He complained of pain in the TMJ bilaterally and a progressive limitation of opening of the mouth. At the time of presentation, maximal interincisal opening was 2 to 3 mm, and bilateral ankylosis, canting of the occlusal plan, retrognathism, open bite, and facial asymmetry were present (Fig 4A). Radiologic examination showed complete bony ankylosis including the coronoid process (Figs 4B,C). Via only a preauricular approach, the ankylotic mass with coronoid process were resected radically on the right side and resection of the condyle was carried out on the left side to create an
FIGURE 4. Case 3. A, Male child who was involved in a road traffic accident, had limited mouth opening, open bite, and severe deviation of the dental midline. B, Orthopantomogram, showing undefined TMJ with a gross ankylotic mass on the right side. C, Computed tomography section in the frontal plane, showing complete loss of the right joint space caused by bony ankylotic mass (black arrow), extended mainly medially and narrowing in the left joint space. D, View of the patient showing 35 mm mouth opening 8 months postoperatively. E,F, Eightmonth postoperative radiographic appearance (computed tomography and panoramic) showing the grafts without fixation in normal anatomic position incorporated perfectly into the ascending ramus bilaterally (artifacts on the right side are belong to vascular clips). Güzel, Saraç, and Arslan. TMJ Reconstruction. J Oral Maxillofac Surg 2007.
approximately 10 mm gap bilaterally. Costochondral grafts were tightly inserted into the prepared tunnels in the ascending ramus bilaterally. No fixation to the graft was applied. One month after surgery, the maximal interincisal opening was 35 mm. It remains unchanged (8-months postoperatively) (Fig 4D). Panoramic view and CT of the mandible showed totally remodeled condyles in both side and the distance between the glenoid fossa and bony rib-end were normal bilaterally (Figs 4E,F).
Discussion Costochondral grafts have been used for reconstruction of the TMJ relating to ankylosis, post-traumatic dysfunction, facial asymmetry, neoplastic disease, osteoarthritis, and rheumatoid arthritis.18,19 The goals of TMJ arthroplasty are not only rehabilitation of the complex mechanism of the normal joint, but also restoration of facial skeletal symmetry, occlusal disharmony, and mastication.11 Kaban et al1 recommended costochondral grafts for surgical reconstruction of the TMJ after reporting the advantages and disadvantages of many other techniques. Ostectomy alone gives rise to a gap between the articular cavity and the mandibular ramus and has the disadvantage of generating a pseudo-articulation, with shortening of the mandibular ramus. In addition, it seems to increase the risk of recurrence. Complications such as
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the development of an open bite in bilateral cases, premature occlusion on the affected side with contralateral open bite in unilateral cases, and limited mouth opening postoperatively are possible in such gap arthroplasty. Interposition of autogenous or alloplastic material in the ostectomy site is a mechanism to prevent recurrence, however, there are possible disadvantages,1 including morbidity at the donor site and unpredictable resorption when autogenous material is used, and risk of a foreign body reaction when alloplastic material is used. Use of autogenous materials (costochondral graft, clavicular graft, iliac crest, metatarsus) requires a longer surgical time, and presents risk of morbidity of the donor site.1 The costochondral graft has advantages, however, including biocompatibility, adaptation of the graft to the articular fossa, and potential growth. The autogenous costochondral graft has been considered the most acceptable tissue for reconstruction of the TMJ because of anatomic similarity to the mandibular condyle. However, absence of predictability of the amount of costochondral graft growth and other unusual complications20 have been reported by some authors8,21-23 as disadvantages of the technique. Several authors1,24-28 have reported the combined use of the preauricular and submandibular Risdon’s incisions. These allow adequate visualization of the surgical field, and allow fixation of the costochondral graft that is usually attached to the posterior or the posterolateral border of the ramus of the mandible. However, even with a precise dissection and identification of the mandibular branch of the facial nerve, there remains a potential risk for nerve injury. Fixation with plate screws, several screws, or with a simple wire of the graft to the ramus of the mandible is always necessary and these procedures have some difficulties on practice. The costochondral graft cannot be oriented usually in the anatomic position of the original condyle. In addition, a submandibular incision usually produces a visible scar on the face. The technique discussed in this study has the following advantages: 1) 1 incision (preauricular incision) is sufficient; 2) exposure during the preparation of the recipient bed and application of the graft is easy and has a minimal risk of facial nerve injury because exposure of the whole lateral aspect of the mandibular ramus is not required; 3) the graft can be placed in an anatomic position; for this reason, the graft can be incorporated well into the ascending ramus; 4) although any fixation for stabilization of the graft may not be required, there can be a single screw via a preauricular incision applied easily when a perfect stabilization is desired, in terms of additional security; and 5) there is a complete bone-to-bone contact between the ramus of mandible and the bone
part of the costochondral graft that can provide good bone healing. The new technique described consisted of a costochondral graft application for the TMJ reconstruction that was inserted into the medullary cavity of the mandibular ramus. This modification further stabilized the graft in its position and inhibited its displacement without any fixation. There are some limitations of this technique, including congenital absence of the TMJ (ie, hemifacial microsomia), in which the absence of any ascending ramus would make a second incision necessary. With congenital aplasia, and sometimes with normal mandibles, the width of the ascending ramus will be too narrow to permit the use of an inlay technique. We suggest this technique is best suited for the acquired diseases of the TMJ where the size of the ramus is sufficient. The complication of facial nerve weakness occurs when there is excessive retraction intraoperatively. This usually responds to steroid therapy, and function is regained when the inflammation subsides in 4 to 6 weeks. We used the modified preauricular incision described by Al-kayat and Bramley29 in our patients and perhaps, due to the fact that exposure of the whole lateral aspect of mandibular ramus was not required, we did not see any immediate postoperative facial nerve weakness.
References 1. Kaban LB, Perrott D, Fisher K: A protocol for management of temporomandibular joint ankylosis. J Oral Maxillofac Surg 48: 1145, 1990 2. Lindqvist C, Jokinen J, Paukku P, et al: Adaptation of autogenous costochondral grafts used for temporomandibular joint reconstruction: A long term clinical and radiologic follow up. J Oral Maxillofac Surg 46:465, 1988 3. Mercuri LG: The use of alloplastic prostheses for temporomandibular joint reconstruction. J Oral Maxillofac Surg 58:70, 2000 4. Cope MR, Moos KF, Hammersley N: The compressible silicone rubber prosthesis in temporomandibular joint disease. Br J Oral Maxillofac Surg 31:376, 1993 5. Hensher R: Temporomandibular joint replacement. Br J Hosp Med 53:455, 1995 6. Kent JN, Misiek DJ: Controversies in disc and condyle replacement for partial and total temporomandibular joint reconstruction, in Worthington P, Evans JR (eds): Controversies in Oral and Maxillofacial Surgery. Philadelphia, WB Saunders, 1994, pp 397-435 7. MacIntosh RB: Costochondral grafts, in Bell WH (ed): Modern Practice in Orthognathic Surgery. Philadelphia, WB Saunders, 1992, p 872 8. Figueroa AA, Gans BJ, Pruzansky S: Long term follow-up of a mandibular costochondral graft. Oral Surg Oral Med Oral Pathol 58:257, 1984 9. Wen-Ching Ko E, Huang CS, Chen YR: Temporomandibular joint reconstruction in children using costochondral grafts. J Oral Maxillofac Surg 57:789, 1999 10. Link JO, Hoffman DC, Laskin DM: Hyperplasia of a costochondral graft in an adult. J Oral Maxillofac Surg 51:1392, 1993 11. Lindqvist C, Pihakari A, Tasanen A, et al: Autogenous costochondral grafts in temporo-mandibular joint arthroplasty. A survey of 66 arthroplasties in 60 patients. J Maxillofac Surg 14:143, 1986
620 12. Matsuura H, Miyamoto H, Ishimaru JI, et al: Costochondral grafts in reconstruction of the temporomandibular joint after condylectomy: An experimental study in sheep. Br J Oral Maxillofac Surg 39:189, 2001. 13. Obeid G, Guttenberg SA, Connole PW: Costochondral grafting in condylar replacement and mandibular reconstruction. J Oral Maxillofac Surg 46:177, 1988 14. Peltomaki T: Growth of a costochondral graft in the rat temporomandibular joint. J Oral Maxillofac Surg 50:851, 1992 15. Politis C, Fossion E, Bossuyt M: The use of costochondral grafts in arthroplasty of the temporomandibular joint. J Craniomaxillofac Surg 15:345, 1987 16. Rowe NL: Ankylosis of the temporomandibular joint. Part 2. J R Coll Surg Edinb 27:167, 1982 17. Rowe NL: Ankylosis of the temporomandibular joint. Part 3. J R Coll Surg Edinb 27:209, 1982 18. Saeed NR, Hensher R, McLeod NMH, et al: Reconstruction of the temporomandibular joint autogenous compared with alloplastic. Br J Oral Maxillofac Surg 40:296, 2002 19. Ware WH, Brown SL: Growth center transplantation on replace mandibular condyle. J Maxillofac Surg 9:50, 1981 20. Merkx MAW, Freihofer HPM: Fracture of costochondral graft in temporomandibular joint reconstructive surgery: An unexpected complication. Int J Oral Maxillofac Surg 24:142, 1995
TMJ RECONSTRUCTION 21. Faerber TH, Ennis RL, Allen GA: Temporomandibular joint ankylosis following mastoiditis: Report of a case. J Oral Maxillofac Surg 48:866, 1990 22. Kent JN, Misiek DJ, Akin RK, et al: Temporomandibular joint condylar prosthesis: A ten-year report. J Oral Maxillofac Surg 41:245, 1983 23. Lata J, Kapila BK: Overgrowth of a costochondral graft in temporomandibular joint reconstructive surgery: An uncommon complication. Quintessence Int 31:412, 2000 24. Boon LC, Nik-Hussein NN: Management of ankylosed temporomandibular joint in a young child. J Pedod 14:136, 1990 25. Guyuron B, Lasa CT: Unpredictable growth pattern of costochondral graft. Plast Reconstr Surg 90:880, 1992 26. Hall MB, Brown RW, Lebowitz MS: Facial nerve injury during surgery of the temporomandibular joint: A comparison of two dissection techniques. J Oral Maxillofac Surg 43:20, 1995 27. MacIntosh RB, Henny FA: A spectrum costochondral grafts. J Maxillofac Surg 5:257, 1977 28. Mosby EL, Hiatt R: A technique of fixation of costochondral grafts for reconstruction of the temporomandibular joint. J Oral Maxillofac Surg 47:209, 1989 29. Al-Kayat A, Bramley P: A modified preauricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 17:91, 1979