Customized Alloplastic Temporomandibular Joint Reconstruction: Expanding the Reconstructive "Net"

Purpose: Customized alloplastic temporomandibular joint (TMJ) reconstruction has been well established for refractory ankyloses and arthroses¹, trauma and end-stage TMJ disease in adult patients. However, its use in congenital absence or deficiency of the TMJ in younger patients is not well defined^2,3. The goal of this study was to present outcomes of patients with congenital mandibular defects who underwent customized alloplastic TMJ reconstruction simultaneous with orthognathic surgery.

Methods: A retrospective case series of patients who underwent customized alloplastic TMJ reconstruction concurrent with virtual surgical planning-guided orthognathic surgery (2014-2017) was completed. Anatomic, functional, and complication outcomes were documented.

Results: Five TMJs in 4 patients (1 bilateral, 3 unilateral) were reconstructed. Causes of TMJ absence included Goldenhar Syndrome (2), idiopathic bilateral condylar resorption (1), and post-oncologic in a patient with Gorlin Syndrome (1). The two patients with Goldenhar Syndrome had previous attempts at reconstructive surgery with poor results (distraction, bone grafting, alloplastic implants). All patients were skeletally mature at the time of surgery, had virtual surgical planning and had concomitant maxillomandibular orthognathic surgery at the time of TMJ reconstruction. All patients had improved post-operative occlusal results. Three of 4 patients had >30 millimeters post-operative maximal incisal opening. Complications included revision of implant position (1), ear canal perforation (1), and frontal branch of facial nerve injury requiring secondary brow lift (1). There were no infections or other implant-related complications. Mean follow up was 1.32 years (range, 0.46-2.74 years).

Conclusions: We present a growing series of patients with congenital mandibular defects who underwent successful custom alloplastic TMJ reconstruction with pre-operative virtual surgical planning. Such reconstruction at the time of skeletal maturity for patients with congenital mandibular TMJ defects may present an alternative to existing treatment options, such as mandibular distraction, bone grafting, and prosthesis completed during skeletal immaturity^2,4,5.

References:

1. Dang RR, Mehra P. Alloplastic reconstruction of the temporomandibular joint. J Istanb Univ Fac Dent. 2017;51(3 Suppl 1):S31-S40. doi:10.17096/jiufd.87994.
2. Resnick CM. Temporomandibular Joint Reconstruction in the Growing Child. Oral and Maxillofacial Surgery Clinics of NA. 2018;30(1):109-121. doi:10.1016/j.coms.2017.08.006.
3. Wolford LM, Bourland TC, Rodrigues D, Perez DE, Limoeiro E. Successful reconstruction of nongrowing hemifacial microsomia patients with unilateral temporomandibular joint total joint prosthesis and orthognathic surgery. J Oral Maxillofac Surg. 2012;70(12):2835-2853. doi:10.1016/j.joms.2012.02.010.
4. Tahiri Y, Chang CS, Tuin J, et al. Costochondral grafting in craniofacial microsomia. Plastic and Reconstructive Surgery. 2015;135(2):530-541. doi:10.1097/PRS.0000000000000914.
5. Wan DC, Taub PJ, Allam KA, et al. Distraction osteogenesis of costocartilaginous rib grafts and treatment algorithm for severely hypoplastic mandibles. Plastic and Reconstructive Surgery. 2011;127(5):2005-2013. doi:10.1097/PRS.0b013e31820cf4d6.