Armamentarium

History of the Procedure

The current technique for mandibular ramus/condyle/temporomandibular joint (TMJ) reconstruction using an autogenous rib graft was popularized by Poswillo. However, much credit goes to Sir Harold Gilles, who, in the 1920s, was the first to describe the use of the costochondral graft (CCG). Over the course of time, although other techniques have been tried and tested, the CCG remains a workhorse in the reconstruction of the ramus-condyle unit (RCU) in a growing child and often enough in an adult. The main advantage of the CCG is that it is a biologically compatible autograft that has some growth potential. One of the disadvantages that have been cited in the use of the CCG for reconstruction of the RCU is the unpredictable growth pattern of the graft itself. From their experience, Kaban and Perrott hypothesized that the transferral of a large cartilaginous cap may be the cause of this overgrowth; these authors advocate the use of a 1- to 2-mm cartilaginous cap to avoid this problem. CCGs also tend to be flexible and almost elastic, which often can lead to deformation of these grafts in function. In addition, this predisposes them to intraoperative problems with fixation and the possibility of resorption or failure. Several authors have assessed the long-term fate of CCGs and reaffirmed the challenge of the unpredictability of its growth pattern. In addition to overgrowth, undergrowth and ankylosis have been reported. Reviews by Mulliken et al. suggested that most of the CCG’s growth occurs in the first 2 months after placement and that the graft often does not have a linear pattern of growth, but rather follows a slow, irregular pattern, although there are many variations of this general rule.

A better understanding of CCG growth patterns and rigid fixation techniques, in addition to the ability to simulate and perform virtual treatment planning of the graft, have led to a more predictable technique.

History of the Procedure

The current technique for mandibular ramus/condyle/temporomandibular joint (TMJ) reconstruction using an autogenous rib graft was popularized by Poswillo. However, much credit goes to Sir Harold Gilles, who, in the 1920s, was the first to describe the use of the costochondral graft (CCG). Over the course of time, although other techniques have been tried and tested, the CCG remains a workhorse in the reconstruction of the ramus-condyle unit (RCU) in a growing child and often enough in an adult. The main advantage of the CCG is that it is a biologically compatible autograft that has some growth potential. One of the disadvantages that have been cited in the use of the CCG for reconstruction of the RCU is the unpredictable growth pattern of the graft itself. From their experience, Kaban and Perrott hypothesized that the transferral of a large cartilaginous cap may be the cause of this overgrowth; these authors advocate the use of a 1- to 2-mm cartilaginous cap to avoid this problem. CCGs also tend to be flexible and almost elastic, which often can lead to deformation of these grafts in function. In addition, this predisposes them to intraoperative problems with fixation and the possibility of resorption or failure. Several authors have assessed the long-term fate of CCGs and reaffirmed the challenge of the unpredictability of its growth pattern. In addition to overgrowth, undergrowth and ankylosis have been reported. Reviews by Mulliken et al. suggested that most of the CCG’s growth occurs in the first 2 months after placement and that the graft often does not have a linear pattern of growth, but rather follows a slow, irregular pattern, although there are many variations of this general rule.

A better understanding of CCG growth patterns and rigid fixation techniques, in addition to the ability to simulate and perform virtual treatment planning of the graft, have led to a more predictable technique.

Indications for the Use of the Procedure

• 1.

  Reconstruction of the ramus-condyle unit in growing children

• 2.

  Reconstruction of the ramus-condyle unit in disarticulation resections of the mandible in adults

• 3.

  Reconstruction of other continuity defects or articulation defects in the adult mandible and maxilla

• 4.

  Costal cartilage grafts for reconstruction of cartilaginous defects in the ear and nose

• 5.

  Additional bone graft strut to complement another autogenous cancellous marrow graft harvested from elsewhere, often as a crib or a sandwich

Limitations and Contraindications

Technique: Costochondral Graft Harvesting