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Temporomandibular joint, skull base and mandibular ramus functional reconstruction with homologous bank tissue and free flap.
A case report with 30 months follow-up.

Massimo Maranzano MD ¹, Roberto Rizzo MD ¹, Alessandro Cicognini MD ¹, Renzo Sorato MD ¹, Guglielmo Recchia MD ¹, Raffaella De Grazia MD ², Francesco Di Paola MD ³, Adolfo Paolin MD ⁴ and Giovanni Mazzoleni MD ¹

1-Maxillo Facial Unit, ULSS 9 “Ca’ Foncello” Regional Hospital Trust, Treviso
2-ICU, ULSS 9 “Ca’ Foncello” Regional Hospital Trust, Treviso
3- Radiological Unit-Neuroradiology, ULSS 9 “Ca’ Foncello” Regional Hospital Trust, Treviso
4-Tissue Bank, ULSS 9 “Ca’ Foncello” Regional Hospital Trust, Treviso

 
Introduction

Big craniofacial resections for highly invasive malignant neoplasm, including skull base and maxillary bones, always represent a difficult chance for the reconstructive surgeon.
In these cases it is not easy to restore anatomy and function simultaneously even adopting complex microsurgical techniques.
In the last years, immediate or secondary reconstruction of maxillary bones together with soft tissues following large oncological defects or late effects of radiation therapy, has been proved as a reliable morpho-functional reconstruction technique especially for the mandible. Moreover another important burst has been the constantly increasing use of homotransplantation of tissues due to the increasing standards of tissue banks especially in general surgery and orthopaedic surgery. In maxillofacial and oral surgery, simple bone homotransplantation for small bone segments reconstruction is becoming a popular technique in order to avoid autotransplantation from both intra oral or extra-oral donor sites such as iliac crest, calvaria and tibia1,2,3,4. Today tissue banks not only offer bone but many different tissues including complex body parts such as upper and lower extremities portions and vessels segments.
In this paper we present a case report of an homotransplantation of a complete temporomandibular joint (TMJ) together with a portion of the medial skull base and mandibular ramus folded with an ante-brachial fascio-periosteal free flap as secondary reconstruction after nearly five years from the removal of a sarcoma of the temporomandibular joint involving the skull base and a follow up of more than 30 months.

 

Case Report

A 58 year old woman had been followed since May 2002, when she had been operated for an osteochondrosarcoma of the right temporomandibular joint with a combined craniofacial resection. After a follow up of almost five years she had been completely re-scanned for secondary recurrence in order to plan for a complete temporomandibular joint reconstruction.
The goal of the reconstruction included skull base, complete temporomandibular joint, and mandibular ramus (Fig.1). Whatever reconstruction option or technique has to be chosen, should consider the fact that this particular area has an high functional impact, as the temporomandibular joint is a double articulation working simultaneously almost 24 hours a day supporting high stress tensions and loads.

Fig.1: Pre-operative images for defects of skull base, complete temporomandibular joint and mandibular ramus

Looking at the orthopaedic experience with homograft for articular reconstruction (i.e. knee or shoulder reconstruction), we have planned an homograft reconstruction from a non-alive donor patient5,6,7,8. For this purpose the Treviso Tissue Bank has been alerted for a compatible donor patient. The matching did not consider HLA system of compatibility as the treatment of the grafted specimen inactivates the HLA system of the tissues, but the side of the reconstruction together with the age of the donor patient compared with the recipient patient.
The donor patient had been a 52 years old lady deceased from a non traumatic cause. The medial skull base, the full temporomandibular joint, including the entire articular capsule and the articular disk and the ligaments, and the mandibular ramus to the mandibular angle had been harvested (Fig.2) with a combined retroauricolar and oral approach in order to minimize scars. Caution had been paid not to alter the face of the cadaver: the donor side has been reconstructed using an acrylic device to completely re-assemble it.

Fig.2: Homograft

The potential donor tissue was selected according to age, gender and morphological characteristics and in compliance with the Italian Guidelines for donor screening to avoid the risk of disease transmission and other potential adverse effects in recipients9. Once retrieved, the bone graft was processed en bloc in the tissue bank laboratory, in order to minimize the risk of contamination, and undergone to longitudinal microbiological control during all the laboratory phases. After processing the bone graft was cryopreserved at -160°C in vapor of liquid nitrogen using the dimethylsulfoxide as a cryoprotectant to improve the biological function and immune tolerance of bone graft10.
Once ascertained that all the serological and microbiological tests carried out and donor and tissue were negative, the bone graft was evaluated as suitable for transplant.
The homograft has been transplanted in the recipient patient after the pre-implantation protocol had been fulfilled. A paralaterofacial approach to the temporo-articolar and neck area had been used and the operation time lasted for nearly eight hours in which the cranial base, the complete temporomandibular joint area, the zigomatic arch and the mandibular ramus had been put in place and synthesized with titanium miniplates and screws. The capsular ligaments to the articular disk had been reconstructed with accurate suturing (Fig.3). The capsular fluid had been replaced with a ringer lactate solution. In order to guarantee the blood supply to the homograft and to correct the aesthetic defect, a fascio-periosteal free flap from the left antebrachial area had been raised (Fig.4), together with the vascular pedicle11,12. The periosteum had been raised from the radium and had been divided in two portions of which the cranial was placed on the skull base and the caudal on the mandibular ramus (Fig.5). Attention had been used not to cover the articular capsule with periostium, in order to avoid its ossification. The vascular anastomosis had been performed end to end between the radial artery and the superior tiroid artery and end to side between the cephalic vein and the internal jugular vein. A little portion of the flap had been sutured to the skin to check for the vitality of the buried free flap.

Fig.3: Homograft fixed in place

 

Fig.4: The fascio-periosteal free flap (RFFF)

Fig. 5: Insetting of the flap

At the end of the procedure, the patient had been transferred to the ICU for the post-operative care. The post-operative follow up period in the ICU had been uneventful except for a minor bleeding from the neck that required minor treatment. The patient had been dismissed from the ICU after six days and re-admitted in the ward. The remaining period in the ward had been uneventful, for the first ten days the patient had been fed with a NG tube which had been removed after the patient had started a soft diet by mouth. The patient has been scanned to check for the reconstruction (Fig.6). The patient had been dismissed after three weeks.
The follow up since now consisted in clinical examination every three weeks at the outpatient clinic together with X-ray every 3 months, CT scan every 6 months, MR and a Bone scan a year.

Fig.6: 3D reconstruction of TMJ area at 3 weeks postoperatively

 

Post-op X-ray showed good bone fusion and no reabsorption untill 18 mo after the insetting of the homotrasplant (Fig. 7). At the 24 mo X-ray a little bone reabsorption has been noted at the posterior lateral border of the grafted mandible, in the area not covered by the periosteal portion of the free flap. This has stabilized with time and is now well noticeable in the 30 mo X-ray (Fig.8) which shows good bone fusion and good anatomy of the temporo-mandibular joint.

Fig.7: Post-op X-ray at 18 mo showing good bone fusion and no reabsorption of the homotrasplant

 

Fig.8: X-ray showing major reabsorbtion in the insetted homograft at 30 months postoperatively

The follow-up has always been uneventful for local or distant recurrence of the primary tumor, actually the patient has no evidence of recurrent disease, temporomandibular joint function is good with mouth opening of >4.5 cm (Fig.9) and good laterality movements; no particular problems with eating and swallowing; pain is well controlled with no chronic pain killer drug therapy.
Major bone reabsorption has been noticed in the insetted homograft covered with the free flap either looking at the x-ray findings or at the bone scan, which demonstrates a nice intake of the graft (Fig.10).

 

 
Fig.9: Oral aspect of the pt. at 30 mo

 

 

Fig.10: Bone scan showing a nice intake of the graft at 30 months postoperatively

 

Discussion

A complete functional temporomandibular joint reconstruction had been performed using a composite homograft harvested from a non alive donor patient. This should be considered as an innovative technique in head and neck reconstruction as it represents the first reconstruction attempt of this kind and since now, to our knowledge, there has been no previous report in the literature of such a technique. It should be seen as an innovative operation even because it represents the only possible attempt to fully functionally reconstruct a complex area as the temporomandibular joint.
The rationale of adding a fascio-periosteal free flap to the homograft is that such a large and complex graft needs a good blood supply in order to heal properly and that can not be sufficiently supplied by the surgical altered recipient bed. This has been confirmed in the follow up x-ray controls, especially comparing the one done at 18 months post-operatively with the one at 30 months, that show excellent bone union with the patient mandible, good bone ossification of the graft placed under the periostium provided by the free flap and rebsorbtion of the posterior lateral part of the mandible which was not covered by the periostium. This fact demonstrates even that the homograft is bio-degradable, which is of course a basic characteristic for all the implantable materials and that the part of the homograft that is not revascuralized because it has not been covered by the free flap, has completely been eliminated by the patient.
Moreover the free flap can be used to correct for the facial alteration due to the primary demolitive procedure. In this view, the use of a free flap, protects the homograft and grants for good bone healing.
An important role has been played by the Tissue bank in assuring the quality controls for the recipient patient not only for the donor patient screening, but even for the homograft processing before the reimplantation procedure.
This operation can be considered as a starting point for other functional reconstructions of this area, not only after oncological ablations but for other clinical needs such as in post-traumatic reconstructions or in syndromic patients in which the temporomandibular joint area is not present or has not developed properly as, for example, in first or second arch syndromes.

 

References

1. Gaffney DD, Royer RQ, Dockerty MB, Lipscomb PR. Acetone-preserved bank bone in reconstruction of the mandibular ridge. Oral Surg Oral Med Oral Pathol. 1958 Jul;11(7):792-7.
2. Thorn JJ, Sorensen H, Weis-Fogh U, Andersen M. Autologous fibrin glue with growth factors in reconstructive maxillofacialsurgery. Int J Oral Maxillofac Surg. 2004 Jan;33(1):95-100.
3. Whitman DH, Berry RL, Green DM. Platelet gel: an autologous alternative to fibrin glue with applications in oral and maxillofacial surgery. J Oral Maxillofac Surg. 1997 Nov;55(11):1294-9.
4. Eckert SE, Desjardins RP, Keller EE, Tolman DE. Endosseous implants in an irradiated tissue bed. J Prosthet Dent. 1996 Jul;76(1):45-9.
5. Komender J, Marczynski W, Tylman D, Malczewska H, Komender A, Sladowski D. Preserved tissue allografts in reconstructive surgery. Cell Tissue Bank. 2001;2(2):103-12.
6. Zasacki W The efficacy of application of lyophilized, radiation-sterilized bone graft in orthopedic surgery. Clin Orthop Relat Res. 1991 Nov; (272):82-7
7. Marczyński W, Tylman D, Komender J. Long-term follow up after transplantation of frozen and radiation sterilizedbone grafts. Ann Transplant. 1997; 2(1): 64-6
8. Marczyński W, Komender J, Barański M, Krauze K. Frozen and radiation-sterilized bone allografts in the treatment of post-traumatic malformation of bones. Ann Transplant. 1999; 4(3-4):36-40.
9. [National Transplant Center in accordance with the State-Lands Conference.” Guideline for withdrawal, preservation and use of muscolo-scheletrical tissues” National Transplant Center in accordance with the State-Lands Conference 21st march 2002 decision meeting (Rep.Acts n.1415 Presidence of Ministry cabinet)].
10. Egli RJ, Wingenfeld C, Holze M., Hempfing A, Fraitzl CR, Ganz R, Leuning M. Histopathology of cryopreserved bone allo- and isografts: pretreatment with dimethyl sulfoxide. J Invest Surg. 2006 mar-Apr; 19(2): 87-96
11. Villaret DB, Futran NA. The indications and outcomes in the use of osteocutaneous radial forearm free fap. Head Neck 2003;25:475-481
12. Richardson D, Fisher SE, Vaughan DE, Brown JS. Radial forearm flap donor site complications and morbidity: a prospective study. Plast Reconstr Surg 1997; 99:109-115.

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ll caso clinico presentato è stato oggetto di un case report pubblicato su Microsurgery 30:73–78, 2010.

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Correspondence and requests for off prints:
Mr Massimo Maranzano
Department of Surgery
Maxillofacial Surgery Unit
“Ca’ Foncello”, Regional Hospital Trust
1, Ospedale Sq, 31100 Treviso, Italy.
Tel: +39-347-5610096;
Fax: +39-0422-322365;
E-mail: massimomaranzano@gmail.com
www.maranzano.com

 

Articolo ricevuto il 7 gennaio 2010
Pubblicato on line il 1 marzo 2010

Collabora con Oralmax.it