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3 authors, including:
Hakan Arslan
stanbul University, Cerrahpaa Medical Sc
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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,
0278-2391/07/6504-0004$32.00/0
doi:10.1016/j.joms.2005.12.061
615
616
TMJ RECONSTRUCTION
No.
Age
(yrs)
Gender
Clinical Characteristic
Aetiology
10
46
17
35
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
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
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.
Gzel, Sara, and Arslan. TMJ Reconstruction. J Oral Maxillofac
Surg 2007.
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
618
TMJ RECONSTRUCTION
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
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