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Mandibular Condyle Reconstruction With Inlay

Application of Autogenous Costochondral Graft
After Condylectomy: Cerrahpaa's Technique
Article in Journal of Oral and Maxillofacial Surgery May 2007
DOI: 10.1016/j.joms.2005.12.061 Source: PubMed

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J Oral Maxillofac Surg

65:615-620, 2007

Mandibular Condyle Reconstruction With

Inlay Application of Autogenous
Costochondral Graft After Condylectomy:
Cerrahpasas Technique
M. Zeki Gzel, MD,* Hakan Arslan, MD,
and Mesut Sara, MD
Purpose: Mandibular condyle reconstruction with free costochondral grafting is the most common

method because of some advantages, such as its biological and anatomic similarities to the condyle, and
growth potential in juveniles. Application techniques of the costochondral graft were reported in
numerous articles with several advantages and disadvantages up to now. The purpose of this article is to
present a new modification in application of the costochondral graft to the ramus of the mandible. This
technique is pretty simple, but very effective.
Materials and Methods: The new technique described here consisted of a costochondral graft
application for temporomandibular joint reconstruction, which was inserted into the medullary cavity of
the mandibular ramus in 4 patients. This modification provided the graft placement as anatomical as the
original condyle and further stabilized the graft in its position and inhibited its displacement without any
fixation. This technique is pretty simple because an additional incision to the preauricular, facial nerve
dissection, wide exposition and stabilization efforts are not required.
Results: Clinical and radiological evaluations on 14-month mean follow-up of 4 cases showed very
satisfactory functional results with normal anatomic adaptation and configuration. In all cases, function
of mandible was considered to be good with at least maximal interincisal opening of 30 mm. Good
anatomical position of the graft and good bony healing were seen on the radiographs. Additionally, there
was no need for postoperative intermaxillary fixation.
Conclusion: With this technique, temporomandibular joint reconstruction by the costochondral graft
can be performed as far as possible to the original condyle position.
2007 American Association of Oral and Maxillofacial Surgeons
J Oral Maxillofac Surg 65:615-620, 2007
The indications for temporomandibular joint (TMJ)
reconstruction are well-established and include ankylosis, severe osteoarthritis, rheumatoid arthropathy,

neoplastic disease, post-traumatic dysfunction, and

congenital disease.1,2 The aims of reconstruction include the restoration of mandibular function and
form, decreased patient disability and suffering, and
the prevention of disease progression.3 The method
of reconstruction, however, is controversial and a
multitude of techniques both autogenous (fibula,
metatarsal, clavicle, iliac, and costochondral) and alloplastic (acrylic, synthetic fibers, ulnar head prosthesis, compressible silicone rubber, and total joint systems) have been described.4-6
The autogenous technique accepted most widely
involves the costochondral graft. The advantages of
this graft are its biologic compatibility, workability,
functional adaptability, and minimal additional detriment to the patient.7 The growth potential of the
costochondral graft makes it the ideal choice in children.8,9

*Professor and Chairman, Department of Plastic, Reconstructive

and Aesthetic Surgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul, Turkey.
Registrar, Department of Plastic, Reconstructive and Aesthetic
Surgery, Istanbul University Cerrahpasa Medical Faculty, Istanbul,
Turkey.
Plastic Surgeon, Private Practice, Istanbul, Turkey.
Address correspondence and reprint requests to Dr Gzel: I.U.
Cerrahpasa Medical Faculty, Department of Plastic, Reconstructive
and Aesthetic Surgery, Cerrahpasa Medical Faculty Hospital, 34303
Istanbul, Turkey; e-mail: zg@e-kolay.net
2007 American Association of Oral and Maxillofacial Surgeons

0278-2391/07/6504-0004$32.00/0
doi:10.1016/j.joms.2005.12.061

615

616

TMJ RECONSTRUCTION

Table 1. CLINICAL FINDINGS OF CASES

No.

Age
(yrs)

Gender

Clinical Characteristic

Aetiology

10

Facial trauma after car

accident at the age of 5

46

17

35

5 mm of mouth opening
Deviated dental mid-line
Unilateral TMJ ankylosis
19 mm of mouth opening
Unilateral
2 to 3 mm of mouth opening
Retrognathia/anterior open bite
Bilateral TMJ ankylosis
Negative overbite that lower incisors overlap the lower
ones with 0 mm of mouth opening
Unilateral TMJ ankylosis

Tumor on the left condyle

Facial trauma after car
accident at the age of 6
Facial trauma

Abbreviations: F, female; M, male; TMJ, temporomandibular joint.

Gzel, Sara, and Arslan. TMJ Reconstruction. J Oral Maxillofac Surg 2007.

Potential problems with the costochondral graft

include fracture, further ankylosis, donor site morbidity, and the variable growth behavior of the
graft.10
The surgical technique for application of costochondral graft to the ramus of the mandible after
condylectomy has been well described.2,7,11-18 Access
is by preauricular and lower border incisions to use
the wires, screws, or plates for the fixation of the
graft. The latter incision is just below the lower border of the mandible and the dissection that is required
to identify the marginal mandibular branch of the
facial nerve has a potential risk for the injury of the
nerve.
The purpose of this study is to present a new
modification in the application of the costochondral
graft to the ramus of the mandible. This technique is
simple, but effective.

Methods and Materials

Three male patients with TMJ ankylosis and 1 female patient with a tumor underwent 5 inlay costochondral graft applications between 2001 and 2004 at
the Department of Plastic, Reconstructive and Aesthetic Surgery, Istanbul University, Cerrahapasa Medical Faculty, Istanbul, Turkey (Table 1). Ankylosis occurred bilaterally in 1 case, and unilaterally in 2 cases.
In the bilateral TMJ ankylosis case, clinical findings
included micrognathia and anterior open bite,
whereas in cases of unilateral TMJ ankylosis, deviation
of the mandible to the affected side and facial asymmetry were present. In the tumor case, laterognathia and
prognathia with restricted mouth opening were
present.
SURGICAL TECHNIQUE

All patients were operated on under general anesthesia using nasal fiberoptic intubation. Skin preauric-

ular incision extending to the temporal region, curving backward and upward, posterior of the main
branches of the temporal vessels was carried out. The
incision was carried through the subcutaneous tissue,
the superficial temporalis fascia. Blunt dissection was
carried out downward, to a point 2 cm above the
zygomatic arch where the deep temporalis fascia
splits into 2 layers containing fatty issue. The periosteum was incised on the most posterior aspect of the
arch and this flap, including the zygomatic and temporal branches of the facial nerve, was retracted forward under the periosteum. Dissection was continued downward to the subcondylar region
subperiosteally. The ankylotic mass was resected radically at the subcondylar region to create an approximately 8 to 10 mm gap, with an electrical saw initially
and completed with chisel until movement of the
mandible was noted (Figs 1A,B). A 50-mm costochondral graft including about 15 mm of cartilage was
harvested from the ninth or tenth rib. A cavity was
created by a burr in the ramus, leaving only a 1.5 to 2
mm peripheral cortical bone around the stump (Figs
1C,D). The depth and the size of the tunnel created in
the ramus was designed according to the graft; the
depth of the tunnel was carved as deep as two thirds
of the length of the costochondral graft that was
approximately 25 to 30 mm in our cases. Excavation
of the ramus as long as 15 mm can also be adequate.
The remaining one third of the graft that consists of
mainly a cartilaginous part and an osseous component
was placed outside of the tunnel. The width of the
tunnel was adjusted exactly the same or a bit smaller
than the graft. The bony segment of the graft was
rounded slightly for a tight fit and the cartilaginous
end was reduced to 4 to 5 mm to conform to the
glenoid fossa. In this manner, when the graft is inserted into the cavity, it cannot move easily in any
direction even without any fixation (Figs 1E,F). Although there was no need to fix the grafts in all cases,

617

GZEL, SARA, AND ARSLAN

structed to increase the use of the jaw. Exercises were

gradually intensified, and protrusive and lateral movements were added later. Progress was evaluated by
means of a ruler. No apparatus or exercise device for
passive mobilization was used.

Report of Cases
CASE 1

FIGURE 1. Operative technique. A, Intraoperative photograph showing condylectomy with saw and chisel. B, Intraoperative photograph
showing about 10 mm gap after condylectomy (black arrow).
C, Intraoperative photograph showing a socket created in ramus of
mandible. D, Corresponding schematic drawing. E, Intraoperative
photograph showing inlay adaptation of the costochondral graft
(black arrow). F, Corresponding schematic drawing.
Gzel, Sara, and Arslan. TMJ Reconstruction. J Oral Maxillofac
Surg 2007.

we preferred to use 1 screw with a washer in the first

case, and 1 screw in the second case for additional
stabilization in terms of security. After these experiences, in the last case that was reconstructed bilaterally, we did not use any screw-plate fixation systems.
We did not use any interpositional autogenous tissue
or alloplastic material between the glenoid fossa and
cartilage end of the graft. Intermaxillary fixation was
only applied intraoperatively to determine the graft
position and to facilitate the trimming.
Postoperative maxillomandibular immobilization
was not used in any cases, but patients were in-

A 10-year-old male presented with right high subcondylar and right zygomatic fractures after a road
traffic accident at the age of 5 years. The fractures
were untreated and mouth opening decreased with
time. At the time of presentation, maximal interincisal
opening was 5 mm (Fig 2A). Radiologic examination
showed complete bony ankylosis, extending mainly
medially on the right TMJ (Fig 2B).
Using only a preauricular incision, a gap was produced below the ankylosed segment at the level of
the condylar neck with an electrical saw and osteotome. There were no meniscal remnants. A costochondral graft 50 mm in length including 20 mm of
cartilage was then harvested from the ninth rib. After
the graft was inserted according to the technique
mentioned above, graft stabilization was achieved
perfectly. In terms of security, 1 screw and a washer,
which was custom-made from the single hole of the
miniplate, were used to fix the costochondral graft.
One month after surgery, the maximal interincisal
opening was 30 mm. It remains unchanged (3-years
postoperatively) with acceptable facial symmetry (Fig
2C). Occlusal canting and dental midline relationship

FIGURE 2. Case 1. A, Male child with multiple scars on the right

cheek subsequent to a traffic accident, limited mouth opening, and
marked deviation of the dental midline. B, Computed tomography
section in the axial plane showing the major part of the ankylotic mass
extends medially. C, View of the patient showing 30 mm mouth
opening 1-year postoperatively. D, One-year postoperative photograph of the patient, showing near normal occlusion. E,F, Three-year
postoperative radiographic appearance. The graft in normal anatomic
position incorporated perfectly into the ascending ramus.

FIGURE 3. Case 2. A, Female referred with a slowly growing tumor

in the left preauricular region. B,C, Orthopantomogram and computed
tomography section in the frontal plane, showing a expansile and lytic
tumor in her left condyle and obliteration of the joint space. D, View of
the patient, showing 40 mm mouth opening 1 year postoperatively. E,
One-year postoperative photograph of the patient, showing near
normal occlusion. F, Radiographic appearance 1 year later. The graft
in normal anatomic position incorporated perfectly into the ascending
ramus.

Gzel, Sara, and Arslan. TMJ Reconstruction. J Oral Maxillofac

Surg 2007.

Gzel, Sara, and Arslan. TMJ Reconstruction. J Oral Maxillofac

Surg 2007.

618

TMJ RECONSTRUCTION

also was corrected and near normal occlusion was

achieved (Fig 2D). Panoramic view and computed
tomography (CT) of the mandible showed a totally
remodeled condyle on the right side and the distance
between the glenoid fossa and bony rib-end was the
same as the nonaffected side (Figs 2E,F).
CASE 2

A 46-year-old female, who was referred with a rapidly

growing tumor in the left preauricular region, had complained of pain in the left TMJ and a progressive limitation of opening of the mouth. At the time of presentation, maximal interincisal opening was 19 mm, and
lack of mandibular function, chin deviation, prognathism, and facial asymmetry were evident (Fig 3A).
Radiographic examination showed an expansive and
lytic bone process in the left condyle (Figs 3B,C). Via
only a preauricular approach, an extracapsular resection of the tumor with a part of the ramus was carried
out (odontogenic fibromyxoma was the result of histopathologic examination). A costochondral graft of
appropriate length was inserted into the prepared
tunnel in the ramus according to the technique mentioned above. Although stabilization of the graft was
achieved perfectly, fixation with only 1 screw was
applied for additional security. One month after surgery, the maximal interincisal opening was 40 mm.
The dental midline relationship also was corrected
and near normal occlusion was achieved with her
old prosthesis and is currently unchanged (1-year
postoperatively) with acceptable facial symmetry
(Figs 3D,E). Panoramic view of the mandible
showed a totally remodeled condyle on the left side
(Fig 3F).
CASE 3

A 17-year-old male was involved in a road traffic

accident at the age of 6 years. At the time of the
injury, he sustained a right subcondylar fracture with
marked lateral displacement of the head of the condyle,
left subcondylar fracture with minimal anterior displacement of the head of the condyle, and right paramedian
fracture of the mandible. He was treated elsewhere by
open reduction and a wire osteosynthesis across the
paramedian mandible fracture. He complained of pain
in the TMJ bilaterally and a progressive limitation of
opening of the mouth. At the time of presentation,
maximal interincisal opening was 2 to 3 mm, and
bilateral ankylosis, canting of the occlusal plan, retrognathism, open bite, and facial asymmetry were
present (Fig 4A). Radiologic examination showed
complete bony ankylosis including the coronoid process (Figs 4B,C). Via only a preauricular approach, the
ankylotic mass with coronoid process were resected
radically on the right side and resection of the condyle was carried out on the left side to create an

FIGURE 4. Case 3. A, Male child who was involved in a road traffic

accident, had limited mouth opening, open bite, and severe deviation
of the dental midline. B, Orthopantomogram, showing undefined TMJ
with a gross ankylotic mass on the right side. C, Computed tomography section in the frontal plane, showing complete loss of the right joint
space caused by bony ankylotic mass (black arrow), extended mainly
medially and narrowing in the left joint space. D, View of the patient
showing 35 mm mouth opening 8 months postoperatively. E,F, Eightmonth postoperative radiographic appearance (computed tomography and panoramic) showing the grafts without fixation in normal
anatomic position incorporated perfectly into the ascending ramus
bilaterally (artifacts on the right side are belong to vascular clips).
Gzel, Sara, and Arslan. TMJ Reconstruction. J Oral Maxillofac
Surg 2007.

approximately 10 mm gap bilaterally. Costochondral

grafts were tightly inserted into the prepared tunnels
in the ascending ramus bilaterally. No fixation to the
graft was applied. One month after surgery, the maximal interincisal opening was 35 mm. It remains unchanged (8-months postoperatively) (Fig 4D). Panoramic view and CT of the mandible showed totally
remodeled condyles in both side and the distance
between the glenoid fossa and bony rib-end were
normal bilaterally (Figs 4E,F).

Discussion
Costochondral grafts have been used for reconstruction of the TMJ relating to ankylosis, post-traumatic dysfunction, facial asymmetry, neoplastic disease, osteoarthritis, and rheumatoid arthritis.18,19 The
goals of TMJ arthroplasty are not only rehabilitation of
the complex mechanism of the normal joint, but also
restoration of facial skeletal symmetry, occlusal disharmony, and mastication.11 Kaban et al1 recommended costochondral grafts for surgical reconstruction of the TMJ after reporting the advantages and
disadvantages of many other techniques. Ostectomy
alone gives rise to a gap between the articular cavity
and the mandibular ramus and has the disadvantage of
generating a pseudo-articulation, with shortening of
the mandibular ramus. In addition, it seems to increase the risk of recurrence. Complications such as

619

GZEL, SARA, AND ARSLAN

the development of an open bite in bilateral cases,

premature occlusion on the affected side with contralateral open bite in unilateral cases, and limited
mouth opening postoperatively are possible in such
gap arthroplasty. Interposition of autogenous or alloplastic material in the ostectomy site is a mechanism
to prevent recurrence, however, there are possible
disadvantages,1 including morbidity at the donor site
and unpredictable resorption when autogenous material is used, and risk of a foreign body reaction when
alloplastic material is used.
Use of autogenous materials (costochondral graft,
clavicular graft, iliac crest, metatarsus) requires a
longer surgical time, and presents risk of morbidity of
the donor site.1 The costochondral graft has advantages, however, including biocompatibility, adaptation of the graft to the articular fossa, and potential
growth. The autogenous costochondral graft has been
considered the most acceptable tissue for reconstruction of the TMJ because of anatomic similarity to the
mandibular condyle. However, absence of predictability of the amount of costochondral graft growth
and other unusual complications20 have been reported by some authors8,21-23 as disadvantages of the
technique.
Several authors1,24-28 have reported the combined
use of the preauricular and submandibular Risdons
incisions. These allow adequate visualization of the
surgical field, and allow fixation of the costochondral
graft that is usually attached to the posterior or the
posterolateral border of the ramus of the mandible.
However, even with a precise dissection and identification of the mandibular branch of the facial nerve,
there remains a potential risk for nerve injury. Fixation with plate screws, several screws, or with a
simple wire of the graft to the ramus of the mandible
is always necessary and these procedures have some
difficulties on practice. The costochondral graft cannot be oriented usually in the anatomic position of the
original condyle. In addition, a submandibular incision usually produces a visible scar on the face.
The technique discussed in this study has the following advantages: 1) 1 incision (preauricular incision) is sufficient; 2) exposure during the preparation
of the recipient bed and application of the graft is
easy and has a minimal risk of facial nerve injury
because exposure of the whole lateral aspect of the
mandibular ramus is not required; 3) the graft can be
placed in an anatomic position; for this reason, the
graft can be incorporated well into the ascending
ramus; 4) although any fixation for stabilization of the
graft may not be required, there can be a single screw
via a preauricular incision applied easily when a perfect stabilization is desired, in terms of additional
security; and 5) there is a complete bone-to-bone
contact between the ramus of mandible and the bone

part of the costochondral graft that can provide good

bone healing.
The new technique described consisted of a costochondral graft application for the TMJ reconstruction
that was inserted into the medullary cavity of the
mandibular ramus. This modification further stabilized the graft in its position and inhibited its displacement without any fixation. There are some limitations
of this technique, including congenital absence of the
TMJ (ie, hemifacial microsomia), in which the absence of any ascending ramus would make a second
incision necessary. With congenital aplasia, and sometimes with normal mandibles, the width of the ascending ramus will be too narrow to permit the use of
an inlay technique. We suggest this technique is best
suited for the acquired diseases of the TMJ where the
size of the ramus is sufficient.
The complication of facial nerve weakness occurs
when there is excessive retraction intraoperatively.
This usually responds to steroid therapy, and function
is regained when the inflammation subsides in 4 to 6
weeks. We used the modified preauricular incision
described by Al-kayat and Bramley29 in our patients
and perhaps, due to the fact that exposure of the
whole lateral aspect of mandibular ramus was not
required, we did not see any immediate postoperative
facial nerve weakness.

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TMJ RECONSTRUCTION
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