Reconstruction of Bilateral Mandibular Condyles Using a Single Vascularized Fibula

Patients with end-stage temporomandibular joint (TMJ) pathology present with loss of vertical ramus height with resulting retrognathia, anterior open bite, and restricted jaw function requiring joint reconstruction. Costochondral grafts, long considered the gold standard for TMJ reconstruction, carry risks of bony ankylosis and resorption. Custom-made alloplastic TMJ prostheses show excellent objective and subjective outcomes but are also associated with complications such as infection or metal sensitivity, and necessitate hardware explantation in some cases. Revision surgeries are rare but present a real challenge. We present the case of a 50-year-old woman with longstanding TMJ arthritis, having undergone many surgical procedures to her TMJ, including explantation of failed alloplastic replacement, who presented with bilateral facial weakness as well as difficulty chewing and swallowing food. She had class II malocclusion with retrodisplacement of her mandible and anterior open bite, and moderate trismus with an inter-incisal opening of only 15 mm, consistent with fibrous ankylosis. After weighing all the reconstructive options, bilateral mandibular condyle and ramus reconstruction with a single fibula free flap (FFF) was planned with the use of preoperative virtual surgical planning (VSP) and 3D-printing of osteotomy and repositioning guides. A 2-team approach increases efficiency of the procedure and decreases operative time. The procedure and postoperative recovery were uncomplicated, and at her 2-month follow-up, she had increased range of motion and maintained the planned position of her mandible. Her masticatory function and deglutition were also improved due to the correction of her malocclusion and repair of her anterior open bite.