Key points
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Temporomandibular joint (TMJ) reconstruction restores mandibular function, occlusion, facial form, and airway support in conditions like ankylosis, trauma, and arthritis.
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Alloplastic total joint replacement is preferred in skeletally mature patients due to predictable outcomes and absence of donor-site morbidity.
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Autogenous grafts, particularly costochondral grafts, are favored in children due to growth potential but have variable outcomes.
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Custom TMJ prostheses allow precise anatomic restoration and are beneficial in complex deformities and revision cases.
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Virtual surgical planning enhances surgical accuracy, optimizing implant design, occlusion, and intraoperative execution.
Abbreviations
| CCG | costochondral graft |
| CoCrMo | cobalt–chromium–molybdenum |
| MMF | maxillomandibular fixation |
| NSAIDs | nonsteroidal anti-inflammatory medication |
| TJR | total joint replacement |
| TMJ | temporomandibular joint |
| UHMWPE | ultrahigh-molecular-weight polyethylene |
Overview
Temporomandibular joint (TMJ) reconstruction is indicated in patients with joint destruction secondary to ankylosis, inflammatory or degenerative arthropathies, trauma, neoplasia, congenital deformity, or progressive condylar resorption. The goals of reconstruction are restoration of mandibular form and function, improvement in mastication, speech, airway support, and correction of occlusal and facial deformities. Surgical options include autogenous biologic reconstruction and alloplastic total joint replacement (TJR), each with subtypes and specific use cases. Technique selection is guided by patient age, pathology, prior surgery, and biomechanical considerations. ,
General indications and contraindications
Indications
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Bony or fibrous ankylosis (especially recurrent ankylosis or large heterotopic bone masses) leading to near-complete jaw immobility.
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End-stage degenerative joint disease , such as advanced osteoarthritis or rheumatoid arthritis unresponsive to other treatments.
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Failed previous joint reconstructions , including failed autogenous grafts (eg, costochondral graft [CCG] resorption or ankylosis) or failed alloplastic implants.
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Change in condylar–ramal height due to trauma, resorption, or neoplasia.
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Congenital or developmental abnormalities, such as in hemifacial microsomia or idiopathic condylar resorption.
In general, alloplastic TJR is favored in skeletally mature patients, it provides immediate restoration of joint function, avoids donor site morbidity, and yields more predictable long-term outcomes. Modern TMJ alloplastic devices can be used to manage advanced disease with a reasonable expectation of achieving ∼32 to 50 mm of postoperative opening and significant pain reduction. In contrast, autogenous reconstruction is often preferred in children or adolescents , given the growth potential of autografts (especially CCGs) that can adapt with mandibular development. ,
Contraindications
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Active infection at the surgical site is a strict contraindication—an infected field greatly increases the risk of implant failure and postoperative complications.
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Allergy to implant materials —True nickel or cobalt-chrome allergy, alternative using an all titanium prosthesis.
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Severe systemic conditions that preclude major surgery (for example, unstable cardiac disease or bleeding disorders) would also contraindicate an elective TMJ reconstruction.
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Skeletal immaturity is generally a relative contraindication for alloplastic joints, using a fixed-size device in a growing jaw can lead to secondary deformities; thus, autogenous options are usually recommended for young patients. As more experience and success with TMJ TJR devices are gained and reported, the indications may include patients who have not achieved complete skeletal maturity. In some adolescent patients who have had severe ankylosis and multiple procedures, there is no potential for continued growth in the site of the ankylosed or mutilated joint ; therefore, TMJ TJR may be beneficial in limited cases such as children or adolescents with severe deformities.
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Psychological readiness Careful counseling is essential for those unwilling or unable to participate in rehabilitation or those with psychiatric issues that affect compliance before joint reconstruction.
Autogenous reconstruction
Costochondral grafts
The CCG has historically been the most widely used autogenous option for TMJ reconstruction. Its popularity stems from ease of harvest, anatomic similarity to the mandibular condyle, and presumed growth potential in pediatric patients.
Advantages
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Potential for adaptive growth in children
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Autogenous tissue with no foreign-body reaction
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Ability to reconstruct ramal height and joint continuity
Limitations
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Unpredictable growth (overgrowth or resorption)
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Ankylosis
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Donor-site morbidity
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Increased risk of failure in multiply operated joints or inflammatory conditions
Clinical series demonstrate variable long-term outcomes, particularly in adults and in joints with compromised vascular beds, where graft resorption and ankylosis remain significant concerns.
Other autogenous options
Alternative biologic reconstructions include
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Sternoclavicular grafts
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Metatarsal graft
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Vascularized fibula flaps
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Iliac crest grafts
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Temporalis muscle or fascia flaps (primarily for interposition reconstruction)
Vascularized bone flaps provide improved graft survival in compromised beds but increase operative complexity and morbidity. Soft-tissue interposition alone does not reliably restore joint biomechanics in end-stage disease and is contraindicated in inflammatory arthropathies and multiply operated joints. ,
Alloplastic total joint replacement
Alloplastic TJR provides immediate stability, eliminates donor-site morbidity, and offers predictable long-term outcomes. There are 2 types of alloplastic devices: custom (patient-specific) and stock (off-the-shelf).
Materials
TMJ total joint prostheses use cobalt–chromium–molybdenum (CoCrMo) alloys or titanium alloys for the condyle/ramus component and ultrahigh-molecular-weight polyethylene (UHMWPE) for the fossa. CoCrMo offers strong wear resistance but may trigger nickel hypersensitivity. Titanium alloys (Ti-6Al-4V) are biocompatible and corrosion-resistant, though rare hypersensitivity to aluminum and vanadium hypersensitivity can occur.
Manufacturing of alloplastic temporomandibular joint
Manufacturing relies on either subtractive milling or additive manufacturing (3D printing). Subtractive milling produces components with a refined, homogeneous grain structure and predictable mechanical strength. In contrast, 3D-printed titanium alloys often demonstrate needle-like, nonequilibrium microstructures, increased porosity, and less predictable corrosion and fatigue behavior. Current evidence supports milled components as the more dependable option for load-bearing TMJ prostheses.
Custom alloplastic total joint replacement
Custom TMJ prostheses are designed using patient-specific computed tomography (CT) data and stereolithographic models. They allow precise restoration of mandibular position, ramal height, and occlusion, and are particularly advantageous in complex reconstructions.
Advantages
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Optimal fit and fixation
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Ability to address severe anatomic deformity
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Compatibility with simultaneous mandibular advancement orthognathic surgery
Stages of custom temporomandibular joint replacement
One-stage alloplastic TMJ total joint replacement involves resecting the diseased condyle and immediately placing of the alloplastic device in a single operation.
Indications
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Stable or correctable occlusion,
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Limited ankylosis,
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Preserved/minimally distorted fossa anatomy,
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Minimal need for skeletal or occlusal correction.
Two-stage alloplastic TMJ total joint replacement involves 2 procedures: the initial procedure to remove ankylosis or diseased bone, restore mandibular mobility, prepare the fossa, and place a temporary spacer, followed by the delayed second procedure to insert the definitive custom alloplastic device.
Indications
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Extensive bony ankylosis,
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Severe joint deformity,
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Large TMJ-region tumors,
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Failed prior reconstructions,
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Multiply operated joints requiring accurate postresection planning.
Preoperative planning
Virtual surgical planning
Step 1. Computed tomography acquisition (surgeon)
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Obtain a manufacturer-specific, medical-grade CT scan
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Slice thickness: 0.5 to 1.0 mm
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Zero gantry tilt
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Coverage from at least 2.5 cm above the glenoid fossa to the inferior mandibular border
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Maintain the correct occlusion during the CT scan
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Step 2. Data submission to manufacturer (surgeon)
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Digital imaging and communications in medicine (DICOM) CT dataset obtained in the correct occlusion
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Dental anatomy data:
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Intraoral scan (STL), laser-scanned stone models, or cone beam computed tomography (CBCT)-derived dental data
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Step 3. Data processing and hybrid model generation (manufacturer/design engineer)
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Import CT DICOM data into proprietary planning software.
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Register dental anatomy to the skeletal dataset to eliminate artifact distortion.
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Generate a 1-piece hybrid craniofacial–dental 3-dimensional model with the mandible in the correct occlusion.
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Verify accuracy of occlusal and skeletal alignment before proceeding.
Step 4. Occlusal verification and mandibular positioning (Surgeon–Engineer collaboration)
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Confirm the final occlusion as scanned.
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Verify mandibular position relative to the cranial base.
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Confirm vertical ramus height and symmetry.
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Lock occlusion and mandibular position before bone resection planning.
Step 5. Virtual bone resection planning (design engineer with surgeon approval)
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Define the condylectomy level below the diseased condyle.
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Plan resection to achieve a joint gap typically measuring 15 to 20 mm.
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Identify the need for ipsilateral coronoidectomy.
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Plan removal of ankylotic or pathologic bone when present.
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Evaluate proximity to the cranial base, external auditory canal, and major vascular structures.
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Submit resection plan for surgeon review and approval.
Step 6. Custom alloplastic temporomandibular joint design (design engineer)
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Design patient-specific components using computer-aided design:
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Fossa component: contoured to the temporal bone with appropriate bearing orientation
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Mandibular component: restores ramus height and adapts to the lateral ramus
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Define:
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Screw number, length, and orientation
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Flange extension and component thickness
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Step 7. Virtual plan review and final approval (surgeon)
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Review the complete virtual surgical plan, including:
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Occlusion and mandibular position
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Resection margins
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Device design and articulation
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Surgical guides cutting guides and guides with predictive holes Fig. 1
Fig. 1 ( A , B ) Surgical guides for ramus and fossa.
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Step 8. Alloplastic temporomandibular joint fabrication (manufacturer)
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Manufacture custom mandibular and fossa components according to the approved plan.
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Perform quality control to confirm dimensional accuracy and surface integrity.
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Sterilize and package alloplastic device and guides for operative use.
Surgical technique
Step 1: patient positioning and presurgical preparation
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Prophylactic intravenous antibiotics are administered preoperatively.
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The patient is positioned supine and nasally intubated.
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Short-acting neuromuscular blocking agents are used during intubation to permit intraoperative facial nerve stimulation and identification.
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Adequate ocular protection is applied.
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The external auditory canals are irrigated with a vancomycin solution (1 g vancomycin in 1000 mL normal saline).
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Hair within the surgical field is shaved to approximately 1 cm above the ear helix to ensure complete clearance from the operative field.
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A head wrap is applied to secure the endotracheal tube and isolate the patient’s hair.
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The face and neck are prepared in the standard sterile fashion, with meticulous attention to minimizing contamination and maintaining sterility.
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After sterile draping, an iodophor-impregnated sterile adhesive drape (Ioban, 3M) is applied to cover the entire face and neck, isolating the mouth, nose, and endotracheal tube from the sterile field and creating a watertight seal to minimize salivary contamination during head rotation ( Fig. 2 ).
