Original Article
271
Management of the Temporomandibular Joint
after Ablative Surgery
Klaus Grätz, DMD, MD1
1 Department of Cranio-Maxillofacial and Oral Surgery, University
Hospital of Zürich, Zürich, Switzerland
Craniomaxillofac Trauma Reconstruction 2014;7:271–279
Abstract
Keywords
► temporomandibular
joint
► reconstruction
► tumor
► ablative surgery
► complications
► head and neck
surgery
Joachim Obwegeser, DMD, MD1
Address for correspondence Marius Bredell, BChD, MBChB, MChD,
Department of Cranio-Maxillofacial and Oral Surgery, University
Hospital of Zürich, Frauenklinikstrasse 24, 8091 Zürich, Switzerland
(e-mail: marius.bredell@gmail.com).
Management of the temporomandibular joint in ablative head and neck surgery is
controversial with no standardized approach. The aim of the study was to establish riskbased guidelines for the management of the temporomandibular joint after ablative
surgery.
Analysis of all patients’ records receiving ablative surgery involving the temporomandibular joint in the Department of Cranio-Maxillofacial and Oral Surgery, University
Hospital of Zürich, from 2001 to 2012, was performed, identifying 15 patients and 14
reconstructive procedures. A literature search was done identifying all relevant literature on current approaches. Applicable cohorts were constructed, and relevant risks
were extrapolated. Evaluated studies are not uniform in their reporting with nonhomogeneous patient groups. A diverse approach is used in the management of these
patients with complications such as infection, ankylosis, limited mouth opening, plate
penetration in the skull base, and plate loosening. Risk factors for complications appear
to be radiation, costochondral graft, disk loss, and plate use alone. Clinical data suggest
use of a plate with metal condyle reconstructions and previous radiation therapy as
potential risks factors. Employing literature evidence and cumulated clinical data, a riskbased flowchart was developed to assist surgical decision making. Risk factors such as
radiation, disk preservation, and soft tissue conditions are important complicationassociated factors when planning surgery. Free vascularized fibula grafts appear to have
the least complications that must be weighed against donor site morbidity.
Involvement of the temporomandibular joint (TMJ) in most
head and neck oncological or infective processes is not
common.1 This may be explained by the relative protective
distance from most intraoral tumors that would first infiltrate
the mandibular body with only late extension to the TMJ.
Equally uncommon is the direct infiltration of the TMJ from
cutaneous and subcutaneous tumors, but infiltration due to
larger parotid tumors does occur. Metastatic oncological
disease involvement of the TMJ is also not seen often and is
seldom an indication for ablative surgery.2,3
The TMJ may be afflicted by medial or lateral bony
infiltration of the condylar head or neck that would make
preservation of the condyle impossible or by infiltration from
inferior, mostly due to direct spread from the vertical ramus
or involvement of the surrounding soft tissues or alternatively
due to involvement of the skull base and glenoid fossa.3,4
Infective infiltration from the middle ear is a seldom-seen
occurrence; however, conditions such as osteoradionecrosis
(ORN) and osteomyelitis with condylar involvement are occasionally seen and may be an indication for condylar resection.
received
July 20, 2013
accepted
October 27, 2013
published online
June 12, 2014
Copyright © 2014 by Thieme Medical
Publishers, Inc., 333 Seventh Avenue,
New York, NY 10001, USA.
Tel: +1(212) 584-4662.
DOI http://dx.doi.org/
10.1055/s-0034-1378181.
ISSN 1943-3875.
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Marius Bredell, BChD, MBChB, MChD1
Astrid Kruse Gujer, DMD, MD1
Temporomandibular Joint Reconstruction
Bredell et al.
Preservation of the condylar head with potential benefits
of growth in the growing individual and improved function is
the obvious first choice in the management of tumors in this
area; however, due to oncological safety and limited area for
screw fixation, this approach is not always possible. The
tolerance factor in various institutions regarding the required
safety margin in this area may explain the various approaches
in the same clinical setting. Extracorporeal attachment of the
condyle to the bony component of the free flap is possible,
with good function, although resorption of the condylar head
is common but of apparently minor long-term consequence.5
Early and late management of the involved TMJ varies
greatly, ranging from no substitute, nonvascularized autologous grafts to vascularized grafts to partial or total prosthetic
replacement6–8 (►Table 1). Despite numerous case and comparative case series reports, very few guidelines exist regarding management of resected components of the TMJ in
oncological patients.
Oncological or infective indications for reconstruction of
the TMJ add several compounding factors, namely, scarring
and tissue loss due to previous surgery or destruction and
possible poor vascularization,1 which may lead to an increase
in complications and limited function and decreased quality
of life.
Even in nononcological reconstruction of the TMJ, there
are challenges and significant differences in opinion as to the
correct path to reconstruction. Use of autogenous tissues
appears to be a possibility in a group of patients, especially
those with growth potential.
Literature reports regarding guidelines for treatment selection exist but are mostly experience based and are supported by low levels of evidence. Marx et al published the
largest series of 132 alloplastic condylar reconstructions in
the management 131 tumor and trauma patients with the
limitation of an inhomogeneous group.9
The aim of the study was to establish risk-based guidelines
for the management of the TMJ after ablative surgery. The
goal of this article is to derive a risk-based management
protocol and options for the TMJ in patients after ablative
surgery, excluding internal derangement cases, based on our
case series as well as reports in the literature.
Patients and Methods
An analysis of all patients’ records receiving ablative surgery
involving the TMJ in the Department of Cranio-Maxillofacial
and Oral Surgery, University Hospital of Zürich, from 2001 to
2012, was performed and included. Exclusion criteria were
the preservation of part of the condyle as well as insufficient
data. A Medline- and PubMed-based literature search was
done to identify all literature with the search terms “temporomandibular joint” and “reconstruction.” All studies since
1989 that obtained relevant data on reconstruction after
ablative surgery were evaluated for inclusion. Excluded
were all studies in which the joint resection was due to
internal derangement or chronic pain. In total, seven studies
showing adequate relevant information met the mentioned
criteria (►Table 1).
Craniomaxillofacial Trauma and Reconstruction
Vol. 7
No. 4/2014
All patients in whom surgical removal of at least the
condyle was performed due to oncological or infective involvement of the TMJ were identified by a retrospective chart
review. Included in this group were not only primary but also
patients treated secondary to the primary ablative surgery.
The following information was extracted from the records:
age, gender, initial diagnosis, indication for reconstruction,
radiation therapy or not, reconstructive method, primary or
secondary reconstruction, complications, and function
(►Table 2). Based on our own experiences and the literature,
a “risk for complication”-based workflow of reconstructive
options was derived.
Results
In 15 patients, 14 ablative surgical interventions were recorded, with 14 receiving primary or secondary reconstructive procedures; in one patient, no reconstructive procedure
was performed due to a compounding medical condition
(►Table 2). This patient was excluded from further analysis
due to lack of reconstruction. Eight patients had primary head
and neck cancer, but in only four patients the condyle was
involved due to infiltration, while four suffered from ORN.
One patient suffered from a rare benign tenosynovial giant
cell tumor. Two patients suffered from extensive osteomyelitis, and bisphosphonate osteonecrosis afflicted two patients.
One patient had to be operated on twice due to hypertrophic
bone formation around the metal condylar head and represents the only major complication in our series. She suffered
facial nerve damage during the second surgery in a postradiated field, with the facial nerve lying on the reconstruction plate used in the first surgery (►Fig. 1). Six of the
fourteen reconstruction surgeries took place in a radiated
field, explaining the two plate exposures in an unrelated area,
away from the condylar reconstruction. Two patients received total joint reconstructions combined with one and
in the other two free flaps. Five patients received fibula flaps
alone and one received a vascularized costochondral graft,
while all of the others had metal condylar prostheses with or
without a free flap (►Figs. 2–4). Follow-up ranged from 2 to
84 months with an average of 30 months. In total, five
patients suffered from complications that could be considered acceptable, as they all could be corrected with minor
revision surgery or occlusal adjustment. One patient suffered
from facial nerve damage after a reconstruction plate in
which metal condyle had to be removed in a radiate. In 11
patients, reliable information was obtained regarding mouth
opening of which 9 showed a marked improvement of more
than 5 mm. Three patients had a decrease in mouth opening,
but all could be regarded as functional as no mouth opening of
less than 30 mm was recorded (►Fig. 4).
Options in the management of the TMJ after ablative
surgery as found in the literature vary greatly and are
summarized in ►Table 3. Literature reports are mainly limited case series. Marx et al described the largest series of
patients, consisting of an inhomogeneous that also included
posttraumatic reconstructions.9 Studies relating to this subject are summarized in ►Table 1. Plate exposure, especially in
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272
Table 1 Literature reports on TMJ reconstruction after ablative surgery
No. 4/2014
Reconstructive
method
N
Indication
Disk preservation
Complications
Follow-up
Marx et al9
2008
Metal plate with
condyle
131
61 benign
32 malignant
22 ORN
9 trauma
7 osteomyelitis
Native disk 111
Allogeneic cartilage 8
Allogeneic dura 6
Temporal fascia 5
Sternocleidomastoid
tendon 2
Total 132
Joint pain (n ¼ 2)
Plate loosening
Erosion of external auditory
meatus (n ¼ 1)
Mucosal or cutaneous plate
exposures (n ¼ 6) all in
radiated patients without flap
compared with a total of 30
patients without complications resulting in 2 removals
Not mentioned
Daniel et al12
2004
Titanium condylar head
6
5 malignant
1 benign
Not specified
Mild to severe trismus in 5 of
6 patients
Cross bite in all 6 patients
Average 7.8 y
Carlson13
2002
Titanium plate with
condylar head, delayed
bone graft
16
7 benign
9 malignant
Maintained where possible, removed in 3/16
cases (all malignant)
1x plate exposure (radiation)
1x disarticulation
1x middle cranial fossa
penetration (meniscus
maintained) nonsupportive
occlusion with removal
4x limited mouth opening
(< 25 mm)
1x erosion of temporal bone
not requiring removal
3 patients
> 19 mo
3 patients DOD 7 mo
Patel and Maisel14
2001
Titanium plate with
condylar head
Pectoralis major flap for
soft tissue coverage
4
4 malignant
Not specified
Cross bite(n ¼ 1)
Infection(n ¼ 2)
Facial nerve (n ¼ 1) paralysis
and sensorineural hearing
loss
Extrusion of prosthesis after
radiation with one plate
removal (n ¼ 3)
All complications 5–37 mo
after surgery
Not specified
Tang et al15
2009
Patient-specific total
joint prosthesis vs.
costochondral graft
Costochondral
(n ¼ 28)
Patient-specific total joint prosthesis
(n ¼ 23)
51 benign
Maintained disk?
Temporalis muscle
Costochondral:
(16 complications in 154
patients)
malocclusion (n ¼ 7),
ankylosis (n ¼ 5),
overgrowth (n ¼ 2)
minor infection (n ¼ 2)
Mean 23.3 mo
(Continued)
Bredell et al.
Vol. 7
Date
Temporomandibular Joint Reconstruction
Craniomaxillofacial Trauma and Reconstruction
Author
273
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274
Author
Date
Reconstructive
method
N
Indication
Disk preservation
Complications
Follow-up
Vol. 7
No. 4/2014
Bredell et al.
reoperations 11 in (n ¼ 10)
(incl. recurrence n ¼ 4)
Prosthesis: (18 complications
in 8 patients)
facial nerve weakness
(n ¼ 5), temporary
malocclusion (n ¼ 4),
temporary pain
with maximum opening
(n ¼ 4)
Frey syndrome (n ¼ 3)
infection (n ¼ 2)
reoperations in tumor
recurrence (n ¼ 3)
Guyot et al10
2004
Fibula free vascularized
graft
11 (n ¼ 8 tumor
related)
11 (n ¼ 8 tumor
related)
Disk preservation in all
cases
None
2y
Wax et al11
2000
Fibula free vascularized
graft
17, evaluation done
on 10 survivors
10 malignancy
Removed 2
Partially removed 1
Retained 7
n ¼ 3 Trismus
n ¼ 2 dislocation
n ¼ 1 disappearance of free
grafted condyle
Shortest 12 mo
Abbreviations: DOD, dead of disease; ORN, osteoradionecrosis; TMJ, temporomandibular joint.
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Temporomandibular Joint Reconstruction
Craniomaxillofacial Trauma and Reconstruction
Table 1 (Continued)
Table 2 Patient demographics receiving ablative surgery of the condyle (2001–2012)
Age
Follow-up (mo)
Primary
diagnosis
Indication for
condylar resection
Reconstruction
method
Disk
preserved
Pre-RT
Primary or
secondary
reconstruction
Complications
1
54
20
Lymphoma
ORN
Custom with free flap
No
Yes
Primary
Anterior plate exposure
2
66
8
Squamous cell
carcinoma (SCC)
ORN and failed
fibula flap
Custom with free flap
No
Yes
Secondary
None
3
9
23
Rhabdomyosarcoma
Tumor persistence
Fibula free
vascularized graft
Yes
Yes
Primary
None
4
70
36
SCC tongue base
ORN
Fibula free
vascularized graft
Yes
Yes
Primary
None
5
64
27
Adenoid cystic carcinoma
Tumor infiltration
Plate with
metal condyle
Yes
No
Primary
None
6
67
2
Adenoid cystic carcinoma
Metal condylar
head migration
Fibula free
vascularized graft
No
Yes
Secondary
Facial nerve paralysis
7
54
33
Osteomyelitis
Infective destruction
Fibula with
metal condyle
Yes
No
Primary
None
8
88
30
Perforating otitis externa
Infective destruction
None
None
No
None
Occlusal disturbance
9
64
42
Ameloblastic carcinoma
Tumor erosion
Plate with
metal condyle
Yes
No
Primary
None
10
47
84
SCC tongue
ORN
Fibula free
vascularized graft
Yes
Yes
Primary
Plate exposure
11
66
6
Osteomyelitis
Infective destruction
Fibula free
vascularized graft
Yes
No
Primary
None
12
58
18
Biphosphonate therapy
for metastatic prostate
carcinoma
BON
Fibula free vascularized
graft with metal condyle
Yes
No
Primary
Occlusal disturbance
13
61
38
Biphosphonate therapy
for metastatic breast
carcinoma
BON
Fibula free vascularized
graft with metal condyle
Yes
No
Primary
None
14
35
3
Tenosynovial giant
cell tumor
Tumor persistence
Vascularized
costochondral graft
Yes
No
Primary
None
15
67
12
Adenoid-cystic
carcinoma
Tumor recurrence
Fibula with metal condyle
Yes
No
Primary
None
No. 4/2014
Bredell et al.
Vol. 7
Abbreviations: BON, bisphosphonate osteonecrosis; ORN, osteoradionecrosis
Temporomandibular Joint Reconstruction
Craniomaxillofacial Trauma and Reconstruction
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Temporomandibular Joint Reconstruction
Bredell et al.
Figure 1 Hypertrophic bone around metal condylar replacement.
Figure 2 Osteoradionecrosis of the right mandible.
Figure 3 Composite fibula free vascularized flap in place.
radiated patients, is the most common complication, especially associated with a radiated surgical field. It would appear
as if there is a lower incidence of complications when a fibulafree vascularized graft is used versus metal plate with condylar attachment. It is unclear if disk preservation plays a role,
but several authors attempted to preserve this structure
diligently.10,11 Complications reported are summarized
in ►Table 4. Additionally, a selection of possible risk factors
according to the literature and our experience is listed
in ►Table 5.
In summary, it appears as if free fibula flap reconstructions
have a lower complication rate than a plate with a metal
condyle. Radiotherapy predisposes patients to plate exposure
and is associated with the majority of complications.
Discussion
Due to the limited number of patients requiring reconstructive surgery after ablative surgery, limited evidence-based
information is available.
Craniomaxillofacial Trauma and Reconstruction
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Figure 4 Functional mouth opening 1 year after surgery.
Imaging modalities used in the preoperative determination of involvement of the TMJ in tumor and infective
processes are seldom mentioned in the literature. However,
this should not differ from the currently accepted methods of
using computed tomography (CT) and magnetic resonance
imaging (MRI), as well as positron emission tomography
(PET)–CT. Although ultrasound can be used as well, no data
regarding the use of this diagnostic modality in this setting
were found in the literature. A combination of hard and soft
tissue imaging will optimize the diagnosis of whether TMJ is
involved.
Reports on partial and total reconstruction of the TMJ are
plentiful.16 Equally so are the reports on complications found
in the reconstruction of the TMJ; however, most of these
reports focus on cases in which the indications for reconstructive surgery were due to internal derangement.17
Patients suffering from tumors or chronic infections affecting the TMJ are, however, a unique subset of patients with
common unique risk factors for complications that may
contribute to the importance of decision making. These
factors include primary extensive surgery that affects both
the hard and soft tissues, previous surgeries with resultant
scarring and functional impairments, pre- or postoperative
radiotherapy that may have a negative impact on both hard
and soft tissues, preexisting limited mouth opening due to
direct TMJ, or infiltration of surrounding musculature.14 In
this subgroup of patients, the dentition is often in a poor state
leading to reduced occlusal support and fewer adaptive
abilities due to the burden of extensive surgery and/or
chemo- and or radiotherapy, compounded by more advanced
age.15 From the literature, it is clear that radiation, as well as
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Bredell et al.
277
Table 3 Options in reconstructing subcomponents of the TMJ
Replacement
Options
Condyle
Nothing, metal condylar head (alone or combined with bone graft primarily or as secondary
procedure),9,12–14 Vascularized grafts (fibula, metatarsal, costochondral, DCIA),21
Nonvascularized grafts (costochondral, coronoid, Iliac crest,22 distraction osteogenesis,23,24
homograft25
Disk
Temporalis muscle, dermis graft, dermis fat graft, Silastic sheet, allogenic cartilage or dura,
sternocleidomastoid fascia9,19
Total joint replacement
Custom (patient specific) or standard joint replacement26
Abbreviations: DCIA, deep circumflex ilac artery; TMJ, temporomandibular joint.
Reconstructive method
Complications
Costochondral
Over and undergrowth, infection, malocclusion, displacement, fracture, ankylosis, limited
mouth opening, erosion of the skull base15,22
Fibula free vascularized graft
Complications rare; however, ankylosis and dislocation have been reported27
Metal condylar head
Erosion of the skull base, exposure, penetration in the auditory canal, facial nerve weakness,
plate loosening, malocclusion, limited mouth opening, dislocation, hypertrophic bone9
Total joint replacement
Plate loosening, infection28
Table 5 Reported complications with possible risk factors in partial or total joint reconstruction with the authors’ contribution in
brackets
Reconstruction
Complications (N)
Risk factors
Plate with condyle (n 15 þ2)
Plate exposure (11) malocclusion (7)
Erosion in skull base or middle ear (3)
NVII injury
Radiation
No native or reconstructed disk?
Lack of posterior occlusal support
Costochondral (n 28)
Occlusion (7)
Ankylosis (5) (11 reoperations)
No native or reconstructed disk?
Costochondral graft
Custom total joint (n 23 þ 2)
Frey syndrome
Infection (2)
Tumor recurrence (2)
Facial nerve (5)
Plate exposure (1)
Not identified
Disk?
Fibula (n 28 þ 5)
Trismus (3) and dislocation (2)
Plate exposure (1)
Radiation?
multiple previous surgeries, as expected, plays an important
role in the complication rate and has to be taken into account
in any surgery decision-making process.9 In our case series,
plate exposure, although away from the TMJ area, was
associated with previous radiotherapy.
Similarly, patients with infective conditions such as osteomyelitis represent a group with similar poor tissue conditions with the additional risk of infection and bio film
contamination of hardware. More often than not, these
patients are subject to several decortication and sequestrectomy surgeries before definitive ablation. In our case series,
five patients suffered from chronic infection before the
surgery, two of which suffered from post operative complications. Plate exposure developed in a previously radiated
patient who was treated with segmental removal of the plate,
and another suffered from an occlusal disturbance. Although
this case series is small, there seems to be no contraindication
to the replacement of the condyle in an infected area.
With this in mind, it is important to consider the wide
array of surgery- and material-based options in the management of loss of the whole TMJ or only the condylar component
of the TMJ (►Table 3). Due to negative reports regarding
costochondral grafts, there has been a gradual move away
from this practice, favoring free vascularized (especially
fibula) grafts, which show lower complication rates.5,11,19,27
This trend is supported by our clinical observations due to the
improved soft tissue conditions generated by fresh vascularized tissues. In favorable circumstances, the free vascularized
fibula graft can be combined with a metal condyle, a practice
that was employed in four patients with one occlusal
Craniomaxillofacial Trauma and Reconstruction
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Table 4 Commonly reported complications in partial or total joint replacement
Temporomandibular Joint Reconstruction
Bredell et al.
Figure 5 Risk-based flow chart of reconstructive options of the TMJ after tumor surgery.
disturbance noted in this group. In fact 12 of 14 patients with
condylar reconstructions involved concurrent free flap transfer, emphasizing the importance of adequate soft tissue
coverage. The liberal use of free vascularized grafts also
may explain the good mouth opening in this series. In all
recorded patients, a mouth opening of more than 30 mm was
achieved, despite compromised soft tissue conditions due to
radiotherapy and previous surgery scarring.
The use of autogenous fat or dermis fat grafts is well
documented in the literature, and the proposed advantages
of preventing ankylosis or re-ankylosis and improving mobility have been well demonstrated.18 It is now nearly routinely used around alloplastic total joint replacements, and its
successful use has been described as a disk replacement.
Dermis fat graft probably has a role in instances in which
the ingrowth of scar tissue is to be prevented and dermis fat
grafts may be an option where disk replacement is indicated
or fear of ankylosis is present. Although it is a free tissue
transplant, infection is not a common finding.18 Longer-term
studies are indicated in this regard.
Apart from the large case series of Marx et al9 reporting on
a rather-inhomogeneous group of not only tumor patients, no
large series exists regarding the reconstruction of the TMJ in
patients after ablative surgery for tumors or patients suffering
from osteomyelitis. Other literature reports are limited to few
patients, often with a description of a single technique
(►Table 1).20 Despite these limiting factors, there are some
indicators based on careful subanalysis and experience combined with sound clinical judgment on which to base a clinical
decision-making process. Obviously such an analysis lacks
statistical power and has a low level of evidence and should be
interpreted as such. Despite these limitations, there should be
Craniomaxillofacial Trauma and Reconstruction
Vol. 7
No. 4/2014
attention to the reported complications in the different
reconstruction options reported in the literature
(►Table 4). The most common complications appear to be
malocclusion, limited mouth opening, erosion of the skull
base, plate loosening, and infection. These complications
were linked to risk factors (►Table 5) according to the
reported literature and clinical experience in our patient
cohort.
By using the before-mentioned and experience-based risk
factors—namely, pre- or postoperative radiotherapy, covering
soft tissue quality and quantity, the absence of an intact disk,
and loss of occlusal support—a treatment algorithm of management of the TMJ in tumor patients was developed. The
algorithm is based on both risk factors for complications and
structure preservation that should be taken into account in
cases of primary or even secondary reconstruction after
ablative tumor surgery. Low-risk patients can be defined as
those without malignant disease, adequate covering soft
tissue quality and quantity, no radiation, preserved disk,
and sufficient occlusal support. High-risk patients are those
who have been previously radiated, suffer from malignant
disease, have the absence of a disk, and/or have poor occlusal
support. Within each group, the safest method of full or
partial TMJ reconstruction is suggested according to the
risk profile (►Fig. 5).
Conclusion
There is sparse evidence on the optimal reconstruction of the
TMJ after ablative surgery. Decision making in the reconstruction of the TMJ after ablative tumor surgery will remain
challenging. Risk factors for complications such as radiation,
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278
Temporomandibular Joint Reconstruction
12 Daniel E, Browne JD. Minimizing complications in the use of
13
14
Note
This study was presented as an oral presentation at the 4th
World Congress of the International Academy of Oral
Oncology, May 17, 2013.
15
16
Conflict of Interest
The authors herewith deny all possible conflict of interests
related to this article.
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Craniomaxillofacial Trauma and Reconstruction
Vol. 7
No. 4/2014
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disk preservation, and soft tissue conditions must be taken
into account when planning surgery. Free vascularized grafts,
specifically fibula, appear to be the option with the lowest
surgical complication rate and good function that must be
weighed against donor-site morbidity in high-risk cases.
Bredell et al.