Maxillomandibular fixation was not used in any of the patients. Light guiding elastics were used for 3 to 4 weeks. These were removed starting postoperative day 1 for jaw stretching exercise, eating, and oral hygiene.
Treatment of ameloblastomas must be adapted to macroscopic and histologic characteristics of each tumor.31 Recurrence of ameloblastoma is directly related to the surgical approach. Recurrence with conservative treatment (enucleation) is high: from 60% to 90%. Resection with 1 to 2 cm. margin has been shown to result in lower recurrence rates but can be associated with greater morbidity, poor cosmetic, and functional outcomes.
The TMJ can be restored using iliac crest grafts, costochondral grafts, DO, microvascular-free bone flaps, metallic condylar head attached to a reconstruction plate, and alloplastic TMJ prosthesis. The most widely used autogenous graft for TMJ reconstruction is the costochondral graft.32 Possible and not infrequent complications associated with costochondral grafts include fracture, unpredictable cartilage growth, ankylosis, and donor site morbidity like pneumothorax.33–36 The TMJ reconstruction with an alloplastic device appears to be a more predictable option than a costochondral graft.37 The use of a metallic condylar head attached to a reconstruction plate placed directly into the glenoid fossa (with or without retention of the TMJ disc) has been associated with erosion into temporal fossa and middle cranial fossa, plate exposure, and plate fracture.38 Reports using DO to reconstruct the TMJ are rare. The DO has been effective in some clinical reports but the treatment duration is much longer, incorporating the necessary latency, distraction, and consolidation phases. The patient must live with the implanted distractor device for more than 3 months and device failure, graft resorption, and nonunion have been reported.32 Controlling the curvilinear complex mandibular segmental defect in 3 dimensions with DO can be challenging. A second procedure is required for device removal. By contrast, the use of mirroring technology in the planning software used in the patients presented in this report facilitated a predictable restoration of good mandibular contour. Rigid fixation of the device obviated the need for maxillomandibular fixation allowing immediate postoperative jaw opening physiotherapy. No secondary surgery was required.
Another popular technique to reconstruct the TMJ after ablative surgery is the free vascularized fibula graft.7,30 These grafts are ideal for patients who have received, or will receive, radiation therapy.32 Successful healing is commonly reported though the return to good oral function is slower and the donor site morbidity potential is not inconsequential, especially in young, athletically active patients. The available bone volume for subsequent dental implant placement can be variable.
More recently, the use of recombinant human bone morphogenic protein type 2 associated or not with a collagen carrier and allogenic bone graft for restoration of large mandibular defects has been described with good success.39–41 The BMP-2 is an expensive material and as such can still have limited availability in some hospital facilities. Containment of the graft and healing time are other variables that could extend treatment timing. Nevertheless, the use of BMP may well be an interesting future modification to the technique presented in this paper as it could obviate the need to harvest autogenous tissue altogether.
The authors have used alloplastic custom fitted devices coupled with autogenous-free iliac bone grafts. The early results in these 3 patients demonstrate excellent and quick return to good facial form and function. Extensive autogenous tissue harvest (rib and fibula) was avoided. Maxillomandibular fixation was not required, allowing early return to normal oral function. This corroborates with successful results in previously published clinical reports.6,24–28,42,43
Currently available alloplastic TMJ total joint devices (metal head articulating with ultra dense high molecular weight polyethylene fossa) have been in use for over 20 years. Numerous long-term studies have demonstrated their predictability and durability.44–46 These devices are indicated for ankylosis, congenital disorders, condylar fractures, avascular necrosis, failed autogenous grafts, severe inflammatory, and degenerative TMJ disease and tumors requiring extensive resection.47
In the 3 patients presented in this paper, patients underwent TMJ and partial mandibular reconstruction with a hybrid custom alloplastic device coupled with an autogenous-free bone graft. The use of nonvascularized bone grafts provided ample bone volume. This facilitated the subsequent placement of dental implants for restoration of the lost teeth.
The 1 drawback to the presented technique may be the costs associated with the manufacture of the custom device though these costs are conceivably offset by the potential for significantly shorter hospital stays and earlier return to normal life for the patient. Our patients left the hospital after 3 to 4 nights.
Further future study with a larger number of similar patients will be appropriate to confirm the initial favorable results seen in these 3 patients. Future studies should also compare and contrast this technique with the alternative procedures looking at such factors as total cost, hospital length of stay, time to return to normal oral function, and patient satisfaction.
The authors thank to the engineers at Medical Modelling and Zimmer Biomet Microfixation for their role in these patients.
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