Vascularized Bone Graft Reconstruction of the TemporomandibularJoint Using the Tunneled, Anchored Suture Technique

Rahul Seth, MD; Heather H Waters, MD; P Daniel Knott, MD Head and Neck Institute, Cleveland Clinic, Cleveland, OH

ABSTRACTOBJECTIVE:To describe a novel technique that provides a simple, flexible and safe method to approximate and secure the neo-condyle into the glenoid fossa in reconstruction of hemi-mandibulectomydefects.

METHODS:Three patients underwent composite resection of the hemi-mandible with condylectomy. A minimally invasive tunneled suture, anchored with a miniplate to the zygomatic root, was used to approximate the neo-condyle into the glenoid fossa. Post-operative outcomes were assessed with clinical and radiographic measures.

CONCLUSION:The described approach introduces a simple, safe, flexible and effective technique for neocondylar suspension and appropriate realignment during mandibular reconstruction.

The temporomandibular joint (TMJ) is a

diarthroidial joint in which the mandibular

condyle articulates into the glenoid fossa.

Reconstruction of the TMJ may be

required for tumor extirpation, trauma or

osteonecrosis. Re-approximation of an

osseous graft within the glenoid fossa is

critical to reestablish occlusion and allow

mastication. We describe a novel

technique to promote and sustain this

approximation.

INTRODUCTION

Three patients undergoing composite

resection of the hemi-mandible with

condylectomy were evaluated. Surgical

indications included osteoradionecrosis,

bisphosphonate induced osteonecrosis

and a self-inflected gunshot wound. Post-

operative outcomes were assessed with

clinical and radiographic measures.

METHODS

SURGICAL TECHNIQUE

Several reconstructive techniques, such

as costal chondral grafts, titanium

prostheses, calvarial bone grafts and

Alloderm, have been used in

reconstruction of the condylar head.1

Although these techniques describe

reconstruction of the articular surface,

none address sustained retention of the

TMJ. Appropriate approximation is

necessary to promote joint remodeling,

facial symmetry and adequate function of

the TMJ.2-3

DISCUSSION

TMJ reconstruction poses challenges in

osseous graft alignment and suspension.

This novel approach introduces a

technique to securely and efficiently

suspend the osseous graft within the TMJ

during mandibular reconstruction. This

promotes sustained facial symmetry, jaw

opening and dental occlusion.

CONCLUSIONS

Patient 1. 22 Months Post-Op 3D Imaging.

HEAD AND NECK INSTITUTE

1. Khariwala SS, Chan J, Blackwell

KE, Alam DS. Temporomandibular joint reconstruction using a vascularized bone graft with Alloderm. J Reconstr Microsurg2007;23:25-30.

2. Wax MK, Winslow CP, Hansen J,

et al. A retrospective analysis of temporomandibular joint reconstruction with free fibula microvascular flap. Laryngoscope 2000;110:977-981.

3, Thor A, Rojas RA, Hirsch JM. Functional reconstruction of the temporomandibular joint with a free fibular microvascular flap. Scand J Plast Reconstr Surg Hand Surg 2008;42:233-240.

REFERENCES

STUDY DESIGN:Retrospective chart review of a case series was performed.

RESULTS:The median patient age was 64 years. Median follow-up was 19 months.All patients reported improved facial symmetry, jaw opening and acceptable dental occlusion. Post-operative CT imaging revealed sustained approximation within the TMJ without evidence of jaw drift.

The median patient age was 64 years.

Median follow-up was 19 months. There

were no flap failures, infections or

complications. All patients reported

improved facial symmetry, jaw opening

and acceptable dental occlusion without

joint ankylosis. Sustained TMJ

approximation was seen on post-

operative and follow-up CT imaging

without evidence of jaw drift. All patients

tolerated a soft oral diet following surgery.

RESULTS

Mandibular reconstruction was

performed after composite resection

and osteocutaneous graft harvest. A

percutaneous stich was used to

approximate the neo-condyle into the

glenoid fossa. In reconstructing the

TMJ, a pre-auricular incision allowed

dissection of the temporal bone

segment of the zygomatic root. A

1.3mm prolene encircled miniplate was

secured to the zygomatic root using

screw fixation. A hollow awl advanced

the suture inferiorly to the articular

surface of the TMJ where it was

threaded through the

vascularized bone

graft. After the suture

was transferred back

to the miniplate,

applied tension

allowed suspension

of the approximating

graft end to the TMJ

and fixation with

the suture.

Patient 1. 22 Months Post-Op 3D Imaging

Patient 2. 22 Months Post-Op 3D Imaging

Patient 1. Prolene Fixation at Miniplate Patient 2. Coronal CT Demonstrating Condylar

Approximation. Miniplate at Arrow.

Monday, February 1, 2010