A Protocol for the Use of a Combined Microvascular Free Flap with Custom-Made 3D-Printed Total Temporomandibular Joint (TMJ) Prosthesis for Mandible Reconstruction in Children

Abstract

Extended postoperative mandibular reconstructions due to orofacial disease involving the temporomandibular joint (TMJ) in immature patients remain a challenge as a result of ongoing growth, which is usually affected by the disease and treatment. Current reconstructive techniques based fully on alloplastic total joint replacement fail to meet fully the anatomical and functional requirements for the masticatory system and speech development. Fourteen children aged 12.6 ± 2.6 with tumors or congenital deformities affecting the mandible and TMJ were included in the study. Radical surgical treatment according to our own protocol was performed through microvascular anastomotic flap reconstruction of the soft tissues and bones, together with total TMJ custom replacements. Follow-up lasted 2–6 years. During the follow-up, increases in the mandible body (13% growth) and ramus (12% growth) were observed, both of which were related (p < 0.001). This is the first report concerning the immediate reconstruction of the mandible with ramus and total TMJ in children and adolescents that combines a free vascularized graft and total individual prosthesis of the TMJ. The presented technique enabled optimal function of the TMJ, growth of the mandible, and further rehabilitation of the patients. The technique was demonstrated to be safe, reliable, and provide good functional and cosmetic outcomes.

Protocol and Evaluation of 3D-Planned Microsurgical and Dental Implant Reconstruction of Maxillary Cleft Critical Size Defects in Adolescents and Young Adults

“…Iliac crest flap (ICF) is widely used in the reconstruction of orofacial defects, both as a free bone graft usually used for early alveolar grafting and, more recently, as a microvascular bone–soft tissue flap for the large reconstruction of jawbones, including mandible body ramus and TMJ due to the large amount of bone that can be obtained from the recipient site and the possibility of its intraoperative adaptation and modality [ 16 ]. However, in the reconstruction of cleft CSDs, the thick layer of muscle makes the use of ICF challenging in certain cases, and the iliac bone may represent a significant level of resorption [ 35 , 36 ].…”

“…Microvascular tissue transfers require meticulous pre-operative planning; therefore, 3D virtual surgical planning (3D-VSP) is of great importance for reconstructive surgery of the head and neck. 3D-VSP has garnered much interest recently and has clinically proven applicability in the reconstruction of post-resection defects of the mandible [ 16 ].…”

Biomechanical Evaluation of Temporomandibular Joint Reconstruction Using Individual TMJ Prosthesis Combined with a Fibular Free Flap in a Pediatric Patient

“…Mandibular and temporomandibular joint (TMJ) reconstructions are performed to restore the correct function of the mandible and facial symmetry after resection [1][2][3]. The most common disorders that affect the temporomandibular joint and the mandible, which may lead to resection surgery in the pediatric population, are tumors, injuries, ankyloses, congenital deformations [4,5], and juvenile idiopathic arthritis [6][7][8][9].…”

“…While the use of temporomandibular joint prosthesis is the most widely used and considered the treatment of choice in adults for TMJ reconstruction with proven satisfactory long-term results, the optimal protocol for TMJ reconstruction in immature patients remains unclear since children frequently have different pathological backgrounds and desired treatment needs. Data from clinical studies have proven the justified use of microvascularized bone grafting techniques in the reconstruction of the resected mandible in children [1]. Commonly performed is TMJ reconstruction of the condyle ramus with autogenous grafts or distraction osteogenesis [11].…”

Clinical Evaluation of Magnesium Alloy Osteosynthesis in the Mandibular Head

“…Titanium alloys are used in skeletal surgery, in both children [1][2][3] and adults [4][5][6][7]. Long screw fixation through the lateral fragment end of the ascending ramus (i.e., distal fragment) has been a well-known procedure for osteosynthesis of the condylar head for approximately the last 30 years [8].…”