Tem p o ro m a n d i b u l a r J o i n t

Reconstruction in the
G ro w i n g Ch i l d
Cory M. Resnick, DMD, MD

KEYWORDS
 TMJ reconstruction  Children  Jaw deformity  Joint replacement

KEY POINTS
 Congenital deformities, pathologic conditions, ankylosis, and progressive resorptive processes are
the most common indications for temporomandibular joint (TMJ) reconstruction in young patients.
 Distraction osteogenesis is a useful tool for mandibular reconstruction, particularly for congenital
deformities or ankylosis, though long-term stability varies by indication.
 Costochondral grafts and free fibula flaps are the most versatile autogenous reconstructive options.
 The use of alloplastic total joint replacement has burgeoned in recent years and may have a role in
pediatric reconstruction, particularly for progressive resorptive diseases.
 Evaluation of the growth pattern plays an important role in planning TMJ reconstruction in children.

INTRODUCTION second-most common of all craniofacial anoma-

lies. HFM occurs in 1 in 5600 live births.1 Most
The temporomandibular joint (TMJ) is a biarthro- cases are isolated and sporadic. HFM variably
dial hinge joint with complex function. The primary affects the structures derived from the first and
growth center for the mandible is contained within second pharyngeal arches, including the orbits,
the joint and is protected only by a thin layer of external and middle ear, cranial nerves, facial
fibrocartilage. Therefore, reconstruction of this soft tissues, and mandible. Several methods for
joint, particularly in growing patients, requires characterization of the mandibular deformity
careful consideration and meticulous technique. have been proposed; the Kaban-Pruzansky classi-
fication system is the most widely used.2
INDICATIONS Patients with Kaban-Pruzansky type I mandib-
The most frequent indication for TMJ reconstruc- ular deformities may not require TMJ construction;
tion is chronic destruction from osteoarthritis. In often the facial asymmetry can be corrected with
young patients, however, osteoarthritis is rare. standard orthognathic surgery after skeletal matu-
Common indications for TMJ reconstruction in rity. Some with type I and most with types IIA, IIB,
the growing child include congenital deformities, and III deformities will benefit from construction.
acquired abnormalities from pathology or anky- For type I, IIA, and some IIB with sufficient ramal
losis, and progressive condylar resorption. bone, construction can be accomplished either
with an osteotomy (vertical ramus or inverted-L)
[Link]

Congenital Deformities or with distraction osteogenesis (DO). For many

type IIB and all type III, the ramus is too diminutive
Hemifacial microsomia (HFM) is the most common for either of these techniques and construction
congenital deformity affecting the TMJ and the

Disclosure Statement: The author has nothing to disclose.

Department of Plastic and Oral Surgery, 300 Longwood Avenue, Boston, MA 02115, USA
E-mail address: [Link]@[Link]

Oral Maxillofacial Surg Clin N Am 30 (2018) 109–121

[Link]
1042-3699/18/Ó 2017 Elsevier Inc. All rights reserved.
110 Resnick

with a graft or flap is necessary. Costochondral are osteochondroma and synovial chondromato-
grafts and vascularized free fibula flaps are most sis; these are extremely rare in children.8 TMJ
commonly used. deformation and destruction from cysts and
Some surgeons advocate for mandibular con- tumors more commonly occurs from neoplasms
struction during growth; others prefer to wait until and odontogenic lesions originating elsewhere,
skeletal maturity. The primary goal for TMJ con- such as the mandibular body and extending in to
struction in HFM during growth (early treatment) the joint or from the necessary extirpative opera-
is to minimize or eliminate the maxillary deformity tion to remove these lesions.9 Reconstructive op-
that otherwise occurs as the maxilla grows to tions and staging vary based on the extent of
meet the asymmetric mandibular position, destruction; need for adjunctive treatment, such
possibly avoiding the need for Le Fort I osteotomy as radiotherapy; desire for dental rehabilitation;
after skeletal maturity. To accomplish this, an open and status of the adjacent structures including
bite is created on the affected side by lengthening the temporal bone, articular disc, and soft tissues.
the constructed ramus and the maxillary occlusal Trauma is the most common instigator of TMJ
plane is gradually leveled using an orthodontic ankylosis in the developed world.10 Infection has
appliance to direct dental eruption and close this historically been the leading cause in third-world
open bite. Outcomes for early treatment in avoid- countries.11 Juvenile idiopathic arthritis (JIA),
ing the need for future surgery, however, have pathology, radiation therapy, and prior reconstruc-
been disappointing, with more than 50% experi- tions with autologous tissue or DO are other
encing recurrent facial asymmetry by skeletal possible causes. A congenital form of TMJ anky-
maturity.3–6 losis may also exist.12
Additional benefits of early treatment include im- TMJ ankylosis is extremely difficult to treat and
mediate improvement in facial symmetry and has a high rate of recurrence. Secondary problems
occlusion, creation of an articulation between the (ie, mandibular and maxillary asymmetry) must
mandible and temporal bone when one is not also be addressed. Kaban and colleagues13
present, and enhancement of psychosocial well- defined a protocol for management of TMJ
being.7 Early TMJ construction in HFM should be ankylosis that centers on aggressive excision of
considered a component of a staged approach the ankylotic mass, ipsilateral and sometimes
to asymmetry correction, with the expectation contralateral coronoidectomy, lining of the fossa
that an additional operation will be necessary at with the native disc or a temporalis myofascial
skeletal maturity. flap, joint reconstruction with DO or a costochon-
After HFM, the next most common syndrome dral graft, early mobilization, and aggressive phys-
with TMJ abnormalities is Treacher Collins syn- ical therapy. Others favor alloplastic joint
drome (TCS). TCS affects 1 in 50,000 live births replacement after excision of the ankylotic mass,
and variably includes a constellation of craniofa- particularly for recurrent ankylosis.14
cial findings, such as coloboma of the lower eyelid,
absence of lateral eyelashes of the lower lid,
Progressive Condylar Resorption
microtia, zygomatic hypoplasia, and bilateral
mandibular ramus and condyle hypoplasia. Some Progressive condylar resorption may occur in
patients with TCS will have retroglossal airway rheumatologic conditions, such as JIA, from ste-
obstruction as a result of mandibular retrognathia. roid use, or of unknown cause. JIA, called juvenile
Many will require mandibular reconstruction; con- rheumatoid arthritis before 1995, is the most com-
siderations regarding technique and timing are mon pediatric rheumatologic condition.15 The
similar to those described for HFM, except when TMJs are affected in 39% to 75% of patients
obstructive sleep apnea necessitates earlier inter- with JIA.16,17 Some affected patients will experi-
vention. A concomitant maxillary and/or midfacial ence condylar resorption, which can be unilateral
operation is often necessary for counterclockwise or bilateral. Bilateral resorption may result in clock-
rotation. Other congenital anomalies, such as wise rotation of the mandible, steep mandibular
bilateral craniofacial microsomia, congenital TMJ plane, long anterior facial height, short posterior
ankylosis, Nager syndrome, and congenital syn- facial height, Angle class II malocclusion, and
gnathia, may also require TMJ construction. anterior open bite. Unilateral disease can create
lower facial asymmetry.15 Some patients will also
have facial pain and limited mouth opening.18
Acquired Deformities
There is little agreement regarding diagnostic
Acquired deformities of the TMJ can occur from and management protocols for TMJ disease asso-
pathology, trauma, infection, ankylosis, or arthritis. ciated with JIA.19 A small percentage of affected
The most common primary neoplasms of the TMJ patients will require TMJ replacement, and the
 TMJ Reconstruction in the Growing Child 111

most appropriate reconstructive technique is location and angle of the osteotomy and device.
decided based on the chronicity of disease, After incision and dissection, an osteotomy is
response to prior treatment, extent of destruction, created in the mandible with minimal periosteal
patient age, and practice preference. stripping and maintenance of a transport segment
Idiopathic condylar resorption (ICR) is a pro- of at least 1 cm in length. A distraction device is
gressive erosive process of unknown cause that then applied to the lateral ramus and secured
is isolated to the mandibular condyles. It most proximal and distal to the osteotomy with screws.
often occurs in females between 15 and 35 years Many devices are available for mandibular DO,
of age and is bilateral and symmetric.20 The including single vector, multi-vector, and curvi-
resorption eventually stops, sometimes when the linear; the appropriate device is chosen based on
rami are level with the sigmoid notches. Facial the procedural goal. Some devices include
findings of ICR are similar to those of JIA, except detachable proximal footplates that simplify de-
that TMJ function is typically preserved in ICR. vice removal by eliminating the need for extensive
Some advocate waiting until the resorption has dissection to retrieve this footplate, which has
been stable for more than 1 year and then perform- been transported superiorly.
ing conventional orthognathic surgery.20 Others Many surgeons use a latency period ranging
advocate for condylectomy and reconstruction from 1 to 5 days,28 though animal and human
during the active phase21 or for total alloplastic models suggest that latency is unnecessary.29,30
joint replacement.22 Distraction then commences at a rate of 1 to
2 mm daily until the desired lengthening is
RECONSTRUCTIVE OPTIONS AND TECHNIQUE achieved. The device is left in place during the
Osteotomy consolidation period, typically 6 to 8 weeks after
completion of distraction. The device is removed
Conventional osteotomies can be used when the thereafter (Fig. 1).
mandibular condyle and disc are functional and a When the goal of distraction is to level the
reproducible centric relation position can be occlusal plane while in the mixed dentition, the
achieved. These may include sagittal ramus, open bite that is created on the affected side by
intraoral or extraoral vertical ramus, or inverted-L ramus lengthening is maintained by an orthodontic
osteotomies. When ramus lengthening and rota- appliance inserted immediately after completion of
tion is required unilaterally, a compensatory active distraction.7 For the first 3 to 6 months, the
releasing osteotomy on the contralateral side is appliance serves as a bite block to maintain the
often necessary, especially in older children, to open bite. The maxillary side of the appliance is
avoid excessive torquing of the unaffected then gradually reduced over the subsequent 1 to
condyle. 2 years to direct eruption of the maxillary teeth
and level of the maxillary occlusal plane.
Distraction Osteogenesis
DO uses natural healing mechanisms to elongate
Autologous Reconstruction
osseous and soft tissue structures. This technique
was first described by Codivilla23 in 190423 and Costochondral grafts (Fig. 2) and free fibula flaps
later popularized in the orthopedic literature by Ili- (Fig. 3) are the most common autologous recon-
zarov.24 DO was adapted to the facial skeleton in structive options used for the TMJ. Many other
1926 by Wassmund and colleagues,25 but cranio- grafts and flaps, including coronoid process,31
facial DO did not become popular until after ilium,32 femoral medial epicondyle,33 vascularized
McCarthy and colleagues’26 landmark 1992 publi- costochondral,34 and sternoclavicular,35 have also
cation on the application of DO to the mandible. In been used. These grafts are versatile and have
comparison with conventional techniques, DO has been used successfully for mandibular recon-
the following advantages27: (1) eliminates bone struction for decades. Costochondral grafts, how-
grafting and donor site morbidity, (2) augments ever, are composed primarily of cortical bone and
hard and soft tissue structures, (3) increases sta- depend on surrounding recipient tissues for revas-
bility when used for certain indications, (4) de- cularization; thus, some postoperative resorption
creases neurosensory impairment, (5) decreases is expected and some grafts will experience exten-
blood loss, (6) decreases operative time, and (7) sive or complete resorption over time. Resorption
shortens hospital length of stay. is of particular concern when no native soft tissue
For mandibular DO, preoperative virtual surgical envelope exists to accept the graft, such as in
planning based on computed tomography (CT) HFM whereby both the mandibular condyle/ramus
scan is often performed. Three-dimensionally and the surrounding soft tissues may be hypoplas-
printed cutting guides are created to dictate the tic. Vascularized flaps are more resistant to
112 Resnick

Fig. 1. A 3-year-old girl who had resection of a left TMJ ankylotic mass and reconstruction with DO and a tem-
poralis myofascial flap. (A–D) Preoperative photographs showing deviation of the mandible with a left posterior
crossbite and limited opening. (E) CT demonstrating fibro-osseous ankylosis of the left TMJ. (F) Virtual plan for
resection of the ankylotic mass and coronoid process, an additional osteotomy of the ramus to create a transport
segment, and distraction of the segment to create a posterior open bite on the affected side. (G) Intraoperative
markings of planned osteotomies for resection of the ankylotic mass and coronoid process. (H) Specimens. (I)
Maximal incisal opening of 40 mm after resection of ankylotic mass. (J) Planned ramus osteotomy to create trans-
port segment for distraction. Screw holes for the distraction device have been marked in the proximal and distal
segments. (K) After the ramus osteotomy is completed, the distraction device is inserted and the activation arm
emerges from the submental skin. (L) A temporalis myofascial flap is inserted to line the neo-joint. (M) Intraoper-
ative CT image demonstrating device positioning. (N, O) Panoramic radiographs taken immediately postopera-
tively (N) and after 10 mm of distraction (O). (P) One-year postoperative photograph.

resorption compared with grafts.36 There is fat.13,37,38 The mandible is repositioned to achieve
emerging evidence that free fibula flaps are asso- the planned final dental occlusion, and intermaxil-
ciated with a high rate of late joint ankylosis lary fixation is applied. Some surgeons insert an
when used for TMJ reconstruction in growing pa- interocclusal splint to introduce a 2- to 3-mm
tients. (Resnick CM. Ankylosis after construction open bite on the reconstructed side, which is
of the mandibular ramus with free fibula flaps in maintained for several weeks postoperatively, to
growing patients with hemifacial microsomia. Un- compensate for expected resorption and remodel-
published data, 2017.) ing, particularly when using a costochondral
Preoperative planning is typically performed graft.39
using model and/or 3-dimensional virtual surgery The graft or flap is harvested and shaped. Main-
to determine the expected final mandibular posi- taining no more than 2 to 4 mm of cartilage has
tion and the size and shape of the graft or flap. been suggested to minimize the likelihood for
During the operation, the TMJ is accessed by an future overgrowth of the graft.39 The graft or flap
open or endoscopically assisted approach.27 The is then inserted and positioned, with caution to po-
diseased condyle/ramus is resected or reshaped sition the neo-articular surface within the glenoid
as necessary. The disc is preserved if possible. If fossa. Malpositioning, particularly lateral posi-
the disc cannot be maintained, a discectomy is tioning adjacent to the zygoma, increases the
performed and the neo-joint is aligned with risk for ankylosis. The graft or flap is then rigidly
the temporalis muscle and fascia, dermis, or fixed to the native mandible. If a flap is used,
 TMJ Reconstruction in the Growing Child 113

Fig. 1. (continued)

recipient vessels are harvested and anastomoses such as while awaiting pathologic diagnosis or
are performed. during a staged reconstructive approach and/or
for patients who may not tolerate long and exten-
sive procedures.
Alloplastic Reconstruction
The use of alloplastic total TMJ replacement has
The earliest form of alloplastic TMJ reconstruction increased exponentially in recent years.43 Initial
was a rigid fixation plate with a condylar pros- concerns about longevity of these joints is no
thesis. Although some surgeons report good re- longer a barrier,44,45 and some surgeons advocate
sults with this technique,40,41 others have for their use in selected children.46 Several allo-
experienced a high complication rate when using plastic joints (stock or custom prosthesis) are
a plate as the sole implant for TMJ reconstruc- currently available.
tion.42 Since the popularization of total alloplastic After exposure via a preauricular approach, the
joints, plates with condylar prostheses have been native joint is debrided and recontoured as
largely reserved for temporary reconstruction, necessary. In the case of a customized joint
114 Resnick

Fig. 1. (continued)

replacement, presurgical planning guides the fossa component of the joint is inserted and fixed
resection to match the unique joint prosthesis. with screws. Through a separate submandibular
The mandible is then repositioned as planned, incision, the ramus/condylar component is
and maxillomandibular fixation is applied. The inserted and fixed with screws. Before closure,
 TMJ Reconstruction in the Growing Child 115

Fig. 2. A 10-year-old boy who had right TMJ gap arthroplasty with disc preservation and reconstruction with cost-
ochondral graft for ankylosis. (A–C) Preoperative photographs demonstrating mandibular hypoplasia and limited
maximal incisal opening. (D) CT with right TMJ fibro-osseous ankylosis. (E) Ankylotic mass with planned osteot-
omies marked. (F) Remaining ramus after gap arthroplasty with preservation of the disc. (G) Removed ankylotic
mass and coronoid process. (H) Maximal incisal opening after gap arthroplasty, measuring 46 mm. (I–K) Dental
impressions were obtained intraoperatively and an occlusal splint was fabricated to create a 2-mm right posterior
open bite to allow for graft resorption. (L) Harvested costochondral graft before removal of excess cartilage. The
cartilage cap was trimmed to 2 mm before graft insertion. (M, N) Insertion and fixation of the costochondral graft
and plication of the native disc.

autogenous fat, harvested from the abdomen pattern, potential for progressive joint destruction,
or buttock, is packed around the prosthetic and need for a concomitant operation on the
joint to decrease the risk for heterotopic bone maxilla.
formation.47 The amount of missing or diseased mandible to
be replaced and the need to reconstruct one or
CONSIDERATIONS both sides may influence the type and timing of
reconstruction. Small mandibular defects, for
Considerations for reconstruction of the TMJ example, may be predictably restored with non-
differ based on the extent and laterality of the vascularized grafts, whereas vascularized flaps
required reconstruction, patient age, growth may be better suited to larger spans. When
116 Resnick

Fig. 2. (continued)

malignant or uncertain pathology is resected, tem- performed during growth, maintenance of projec-
porary reconstruction with a titanium plate and tion and symmetry depend on future elongation
condylar prosthesis may be used while the spec- of the constructed hemi-mandible. After osteoto-
imen and margins are assessed, with autologous mies in which the condyle is preserved (ie, sagittal
reconstruction performed secondarily. Possible ramus osteotomy), inherent growth potential is
need for adjuvant radiotherapy or chemotherapy maintained. Depending on the underlying disease
may also influence the reconstructive approach. process that led to the reconstruction, however,
As the condyle is the primary growth center of normal growth may not be expected. Costochon-
the mandible, when TMJ reconstruction is dral grafts often elongate during growth, allowing
 TMJ Reconstruction in the Growing Child 117

Fig. 3. A 6-year-old girl with right predominant HFM and a Kaban-Pruzansky type III mandible. (A, B) Preopera-
tive photographs showing mandibular deviation to the right, retrognathia, microtia, and soft tissue insufficiency.
(C–E) Type III mandible with minimal ramus on the right side. (F) Virtual repositioning of the mandible to provide
occlusion on the left side and create a right posterior open bite. A surgical splint is fabricated to dictate this
planned position during the operation. (G) A free-fibula flap is virtually positioned with one osteotomy to facil-
itate the planned mandibular position and mimic the contralateral mandibular contour, which has been trans-
posed on to the affected side (green). (H, I) Planned fibula flap position. (J) A surgical guide is fabricated to
dictate the length and internal osteotomy of the fibula flap. (K) Intraoperatively, the fibula flap is harvested,
the internal osteotomy performed, and a miniplate applied to provide the planned contours while the flap re-
mains attached to the vascular pedicle. (L) The fibula flap is harvested and an AlloDerm (Allergan, Inc, Parsippany
NJ) cap is applied to serve as the articulating surface. (M) The flap is inserted, contoured, and secured to the
native mandible with lag screws. (N) Microvascular anastomoses are performed to the facial artery and the
external jugular vein. (O) After flap insertion and removal of the occlusal splint, the planned occlusion has
been achieved. (P, Q) Postoperative CT demonstrating the position of the flap. (R, S) One-month postoperative
photographs showing improved projection and symmetry of the mandible. (T) One-year postoperative photo-
graph, just before beginning ear construction.

symmetry to be maintained in some cases.39 In hypertrophy but none experienced linear over-
others, undergrowth or overgrowth of the costo- growth.39 There is disagreement in the literature
chondral grafts may necessitate additional opera- regarding the potential for future growth of free fib-
tions.48,49 In a study of 26 patients who received ula flaps.50–52 Alloplastic implants will be dimen-
costochondral grafts including 2 to 4 mm of carti- sionally stable over time. When used in growing
lage, 3 patients developed lateral contour patients, the condylar component can be replaced
118 Resnick

Fig. 3. (continued)

with an upsized version after skeletal maturity or stability.56 Costochondral grafts may be stable in
an osteotomy can be performed in the native patients with quiescent disease57 but are suscep-
mandibular body to advance the mandible as tible to the same resorptive process as the native
necessary to compensate for growth asymmetry. mandible in the face of active/recurrent disease.
For progressive resorptive processes, timing When arthritis cannot be adequately controlled
and choice of reconstruction is influenced by the and does not burn out, alloplastic reconstruction
expected trajectory of the erosive process. In pa- may be most appropriate.58
tients with JIA, contrast-enhanced MRI is the In ICR, stability cannot be confirmed unless the
only reliable assessment of TMJ arthritis activity.53 ramus has resorbed to the level of the sigmoid
When TMJ arthritis is well controlled with medica- notch. One year of documented quiescence, how-
tion or disease remission, some surgeons advo- ever, indicates a high likelihood of achieving a sta-
cate for conventional orthognathic surgery when ble reconstruction.20 Technetium-99 bone scan
possible;54 others think that the joint loading that may also help determine progression of the
results from mandibular surgery increases the disease.59 Conventional orthognathic surgery
risk for future condylar resorption.55 Synovectomy may be the treatment of choice in patients who
and discectomy alone do not provide predictable have achieved stability.20 Condylectomy and
 TMJ Reconstruction in the Growing Child 119

costochondral graft reconstruction has been management. In: Brennan PA, Schliephake H,
shown to be stable in patients in the active Ghali GE, et al, editors. Maxillofacial surgery. 3 edi-
phase.21 tion. St. Louis (MO): Elsevier; 2017. p. 870–93.
When a concomitant maxillary operation is 8. Liu X, Huang Z, Zhu W, et al. Clinical and imaging
necessary to address the deformity, a stable and findings of temporomandibular joint synovial chon-
predictable replacement option increases the likeli- dromatosis: an analysis of 10 cases and literature re-
hood of a favorable result. As costochondral and view. J Oral Maxillofac Surg 2016;74(11):2159–68.
other nonvascularized grafts will undergo remodel- 9. Saxena S, Kumar S, Pundir S. Pediatric jaw tumors:
ing and some resorption postoperatively, predicting our experience. J Oral Maxillofac Pathol 2012;16(1):
the appropriate maxillary movement during the 27–30.
same operation may be difficult. Vascularized flaps 10. Zimmermann CE, Troulis MJ, Kaban LB. Pediatric
will undergo less postoperative resorption. Allo- facial fractures: recent advances in prevention,
plastic prostheses are the most dimensionally sta- diagnosis and management. Int J Oral Maxillofac
ble and provide a predictable mandibular position Surg 2006;35(1):2–13.
to facilitate a maxillary movement. Custom alloplas- 11. Topazian RG. Etiology of ankylosis of temporoman-
tic implants can be designed using virtual surgical dibular joint: analysis of 44 cases. J Oral Surg
planning to conform to the planned final position Anesth Hosp Dent Serv 1964;22:227–33.
of both jaws.60 12. Gil-da-Silva-Lopes VL, Luquetti DV. Congenital
temporomandibular joint ankylosis: clinical charac-
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SUMMARY
affected individuals. Cleft Palate Craniofac J 2005;
The TMJ is complicated and dynamic. When 42(6):694–8.
congenitally missing or destroyed, the timing and 13. Kaban LB, Bouchard C, Troulis MJ. A protocol for
type of reconstruction must be carefully evaluated. management of temporomandibular joint ankylosis
This point is especially true in skeletally immature in children. J Oral Maxillofac Surg 2009;67(9):
patients, whereby the potential for future growth 1966–78.
after reconstruction should be considered. Autolo- 14. Neelakandan RS, Raja AV, Krishnan AM. Total allo-
gous reconstruction is typically preferred in young plastic temporomandibular joint reconstruction for
patients, but alloplastic implants may play a role in management of TMJ ankylosis. J Maxillofac Oral
certain conditions, such as progressive resorptive Surg 2014;13(4):575–82.
processes that cannot be controlled. 15. Abramowicz S, Kim S, Prahalad S, et al. Juvenile
arthritis: current concepts in terminology, etiopatho-
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