Tiongco Rafael P, Hui Amy, Stern-Buchbinder Zachary, Stalder Mark W, St Hilaire Hugo
Division of Plastic and Reconstructive Surgery, LSUHSC School of Medicine, New Orleans, La.
Plast Reconstr Surg Glob Open. 2021 Jan 25;9(1):e3154. doi: 10.1097/GOX.0000000000003154. eCollection 2021 Jan.
Patients with end-stage temporomandibular joint (TMJ) pathology present with loss of vertical ramus height with resulting retrognathia, anterior open bite, and restricted jaw function requiring joint reconstruction. Costochondral grafts, long considered the gold standard for TMJ reconstruction, carry risks of bony ankylosis and resorption. Custom-made alloplastic TMJ prostheses show excellent objective and subjective outcomes but are also associated with complications such as infection or metal sensitivity, and necessitate hardware explantation in some cases. Revision surgeries are rare but present a real challenge. We present the case of a 50-year-old woman with longstanding TMJ arthritis, having undergone many surgical procedures to her TMJ, including explantation of failed alloplastic replacement, who presented with bilateral facial weakness as well as difficulty chewing and swallowing food. She had class II malocclusion with retrodisplacement of her mandible and anterior open bite, and moderate trismus with an inter-incisal opening of only 15 mm, consistent with fibrous ankylosis. After weighing all the reconstructive options, bilateral mandibular condyle and ramus reconstruction with a single fibula free flap (FFF) was planned with the use of preoperative virtual surgical planning (VSP) and 3D-printing of osteotomy and repositioning guides. A 2-team approach increases efficiency of the procedure and decreases operative time. The procedure and postoperative recovery were uncomplicated, and at her 2-month follow-up, she had increased range of motion and maintained the planned position of her mandible. Her masticatory function and deglutition were also improved due to the correction of her malocclusion and repair of her anterior open bite.
终末期颞下颌关节（TMJ）病变患者表现为下颌支垂直高度丧失，导致下颌后缩、前牙开合以及需要关节重建的下颌功能受限。肋软骨移植长期以来一直被视为TMJ重建的金标准，但存在骨强直和吸收的风险。定制的异体TMJ假体显示出优异的客观和主观效果，但也与感染或金属过敏等并发症相关，并且在某些情况下需要取出硬件。翻修手术很少见，但却是一个真正的挑战。我们报告了一例50岁女性患者，患有长期TMJ关节炎，此前对其TMJ进行了多次手术，包括取出失败的异体置换物，该患者出现双侧面部无力以及咀嚼和吞咽食物困难。她有II类错牙合，下颌后移和前牙开合，中度牙关紧闭，切牙间开口仅15毫米，符合纤维性强直。在权衡所有重建方案后，计划使用术前虚拟手术规划（VSP）和截骨术及重新定位导板的3D打印，采用单块游离腓骨瓣（FFF）进行双侧下颌髁突和下颌支重建。双团队方法提高了手术效率并缩短了手术时间。手术和术后恢复过程顺利，在她术后2个月的随访中，她的活动范围增加，下颌保持在计划位置。由于错牙合的矫正和前牙开合的修复，她的咀嚼功能和吞咽功能也得到了改善。
