Int. J. Oral Maxillofac. Surg.

2024; 53: 911–918

https://doi.org/10.1016/j.ijom.2024.07.009, available online at https://www.sciencedirect.com

Clinical Paper
Reconstructive Surgery

A. Modabber a, S. Raith a,
Accuracy and clinical outcomes of P. Winnand a, S.C. Möhlhenrich b,
A. Bock a, K. Kniha a, F. Hölzle a,
F. Peters a
mandibular reconstruction with a a
Department of Oral, Maxillofacial and Facial

virtually planned deep circumflex Plastic Surgery, University Hospital RWTH

Aachen, Aachen, Germany; bDepartment of
Orthodontics, University Witten/Herdecke,
Witten, Germany

iliac artery flap with stock

temporomandibular joint
prosthesis
A. Modabber, S. Raith, P. Winnand, S. C. Möhlhenrich, A. Bock, K. Kniha, F.
Hölzle, F. Peters: Accuracy and clinical outcomes of mandibular reconstruction
with a virtually planned deep circumflex iliac artery flap with stock
temporomandibular joint prosthesis. Int. J. Oral Maxillofac. Surg. 2024; 53:
911–918. © 2024 The Author(s). Published by Elsevier Inc. on behalf of
International Association of Oral and Maxillofacial Surgeons. This is an open
access article under the CC BY license (http://creativecommons.org/licenses/by/
4.0/).

Abstract. The repair of hemimandibulectomy defects involving the

temporomandibular joint (TMJ) is challenging. This study compared the functional
outcomes and reconstruction accuracy using a deep circumflex iliac artery (DCIA)
flap with and without a virtually planned stock TMJ prosthesis (TMJP) after
hemimandibulectomy. Ten patients were assessed: five with a TMJP (TMJP group)
and five without (control group). A three-dimensional comparison revealed a mean
deviation of 0.11 ± 0.04 mm between the planned and actual DCIA flap with TMJP.
The planned and actual TMJP positions differed by 0.56 ± 0.57 mm in height, 0.33 ±
0.24 mm ventrally/dorsally, and 1.18 ± 0.42 mm medially/laterally. Mouth opening,
laterotrusion, and midline deviation were significantly greater in the control group
than in the TMJP group (P = 0.024, P = 0.008, P = 0.024). The deviation in ventral
Keywords: Free tissue flaps; Iliac crest;
to dorsal translation for the DCIA flap was slightly higher than reported values in the
Computer-aided design; Temporomandibular
literature, while height deviation was comparable. Lower deviations in the literature joint; Maxillofacial prosthesis; Free flaps.
were due to the DCIA flap being used where both TMJs were intact. The in-house
virtually planned DCIA flap with stock TMJP yielded results comparable to more Accepted for publication 12 July 2024
expensive patient-specific prostheses. Available online 20 July 2024

0901-5027/530911 + 8 © 2024 The Author(s). Published by Elsevier Inc. on behalf of International Association of Oral and Maxillofacial
Surgeons. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
912 Modabber et al.

Patients with oral squamous cell carci­ study was to analyse the accuracy of cutting guide. The cutting guide fitted
noma or osteomyelitis of the mandible the implementation of the virtual to this geometry and indicating the
often require bone resection as part of planning; the operations were planned position of the TMJP was 3D-printed.
their treatment. In some cases, the using CAD in the hospital to improve The cutting guide was used in­
condyle has to be sacrificed, leaving the the placement of the stock prosthesis. traoperatively to cut the DCIA flap
temporomandibular joint (TMJ) from the pelvis and to place the TMJP
without function. The current literature on the DCIA flap (Fig. 1B, C). Subse­
provides evidence that the function of quently, the DCIA flap was fitted to the
Materials and methods
the TMJ worsens if the condyle is re­ mandible and an anastomosis was per­
sected1, and that reconstruction is Following approval of the study by the formed on the neck vessels (Fig. 1D).
therefore required. Reconstruction of Ethics Committee of the University
the TMJ can be performed with auto­ Hospital Aachen, the medical records
Analysis of functional outcomes
genous transplants or with alloplastic of patients who had received a DCIA
prostheses. Autogenous transplants, flap between 2015 and the end of 2022 Maximum mouth opening was mea­
such as costochondral or sternoclavi­ were searched retrospectively. The in­ sured during normal clinical patient
cular grafts, work best in children2. In clusion criteria for the study group follow-up, at a minimum of 6 months
adults, alloplastic reconstruction of the (TMJP group) were a hemi­ postoperative. This distance was mea­
TMJ leads to a greater improvement in mandibulectomy with the cut in the sured between the incisal edges of the
function and fewer symptoms than region between the frontal incisors and frontal incisors of the upper and lower
costochondral graft reconstructions3. premolars, and replacement of the re­ jaw. Laterotrusion when the mouth was
Two methods of alloplastic TMJ re­ sected mandible with a DCIA flap and maximally opened was also determined,
construction are commercially avail­ a stock TMJP. The control group as well as the midline deviation in
able. The first is a prefabricated stock consisted of patients with a resected maximum intercuspation. These two
prosthesis, which is fitted to a bone mandible and condyle who had under­ values were measured from the ap­
transplant or to the residual jaw. These gone reconstruction with a DCIA flap proximal space between the frontal in­
stock prostheses are available in a few but without a TMJP. The patients in cisors of the upper jaw to the
different sizes to fit different patients4. the control group were matched as approximal space between the frontal
The second option for treatment is an closely as possible to the study group incisors of the lower jaw.
individual patient-specific prosthesis patients by sex, age, diagnosis, whether
that is fitted to the patient using com­ the surgery was a primary or secondary
Analysis of accuracy
puter-aided design (CAD) techniques. reconstruction, and side of the hemi­
These custom prostheses have shown mandibulectomy. Patients were ex­ The 3D surgical planning models were
similar results after insertion to stock cluded if no three-dimensional (3D) exported from the planning software
prostheses5,6. They are currently used radiograph was performed after sur­ ProPlan CMF 3.01. The postoperative
in complicated cases, such as in patients gery, or if the follow-up radiograph was 3D radiograph was imported into
with missing or deformed anatomical of low quality. ProPlan CMF 3.01, and then the
structures who have undergone mul­ The DCIA flap and the stock TMJP TMJP, maxilla, and DCIA transplant
tiple operations6. The disadvantages of were planned via CAD using ProPlan were segmented. The 3D models and
the custom prosthesis are its higher CMF 3.01 (Materialise, Leuven, preoperative models generated were
price and the time required for manu­ Belgium). The preoperative computed exported to Geomagic Control 2014
facturing. The manufacturing process tomography (CT) scan data were im­ (3D Systems, Rock Hill, SC, USA).
takes at least 8 weeks5, while the stock ported into ProPlan CMF, and 3D The postoperative models were aligned
prosthesis is available immediately if it models of the skull and pelvis were seg­ to the preoperative planning using the
is stored in the hospital, or after a few mented. The resection borders were maxilla as a reference for the best fit
days when it has to be ordered. A fur­ placed on the lower jaw, and then the 3D algorithm.
ther treatment option is to leave the model of the lower jaw was cut according Subsequently, equalization planes
patient without the TMJ. to these borders. Next, a model of the were created at the ventral and dorsal
The aim of this study was to in­ DCIA flap was placed into the man­ osteotomies of the DCIA flap model in
vestigate the functional outcomes of dibular defect. Then, the TMJP was vir­ Geomagic Control 2014. Additionally,
patients who had undergone man­ tually placed on the DCIA flap to fit equalization planes were created at the
dibular reconstruction using a deep inside the fossa of the TMJ (Fig. 1A). sides and top of the TMJP (Fig. 2). The
circumflex iliac artery (DCIA) flap with The TMJP used in the patients in­ difference in the translation and rota­
a stock TMJ prosthesis (TMJP) in cluded in this study was the narrow tion between the planned DCIA flap
comparison to those of patients who prosthesis from Zimmer Biomet and its real position after surgery was
had undergone mandibular re­ (Zimmer Biomet, Warsaw, IN, USA). measured with these equalization
construction using a DCIA flap but 3D models of the prosthesis were pro­ planes. The deviation between the
were left without the TMJ. Either a vided by Zimmer Biomet; these were planned position of the TMJP and its
stock TMJP was fixed to the flap or no modified slightly in the screw positions actual position on the DCIA flap was
reconstruction of the TMJ was per­ and morphology of the condylar head also measured.
formed. The hypothesis investigated from the original prosthesis, in order to The planned and postoperative
was that there would be a significantly prevent product imitation. The outer DCIA flaps were aligned using the best
smaller laterotrusion and midline de­ shape of the body of the prosthesis re­ fit algorithm. After equalization planes
viation when the reconstruction in­ mained the same to enable positioning at the ventral and dorsal osteotomy
cluded a TMJP. The second aim of this of the original prosthesis using the were created, the difference in the angle
 Virtual surgery planning of stock TMJ prosthesis 913

Fig. 1. (A) Computer planning for a patient who received a stock TMJ prosthesis. (B) The raised DCIA flap with the cutting guide and
mounted stock TMJ prosthesis; the flap is still connected to the iliac vessels. The arrow indicates the vascular pedicle. (C) The stock TMJ
prosthesis mounted on the DCIA flap, which is still connected to the iliac vessels. The transplant was placed on the planning model. The
arrow indicates the vascular pedicle. (D) The DCIA flap was fitted and fixed to the mandible. The yellow vessel loop marks the facial
nerve. The arrow marks the anastomosis to the cervical vessels.

of the planned osteotomy and per­ variable volume. The Mann–Whitney because of missing postoperative 3D
formed osteotomy was measured, and U-test was performed for the unpaired radiographs. The control group con­
the volumes of the planned and post­ variables mouth opening, laterotrusion, sisted of five patients who had under­
operative DCIA flaps were compared. and midline deviation. The level of gone a computer-planned DCIA flap
Additionally, a 3D distance compar­ significance was set at P ≤ 0.05. All data reconstruction without a TMJP. The
ison was performed between the were expressed as the mean value ± characteristics of the patients in both
planned and actual DCIA transplant standard deviation. groups are shown in Table 1.
with the TMJP. The measured values for the func­
tional outcomes are reported in
Table 2. Mouth opening (P = 0.024),
Statistical analysis Results
laterotrusion (P = 0.008), and midline
The statistical analysis was performed A total of seven patients who under­ deviation (P = 0.024) were significantly
using GraphPad Prism version 9 went mandible reconstruction with a greater in the control group than in the
(GraphPad Software Inc., San Diego, DCIA flap and a stock TMJP were TMJP group. No patients had pain in
CA, USA). As the data were not nor­ identified in the records. Of these pa­ the TMJ prior to or after surgery.
mally distributed, the Wilcoxon signed- tients, five were eligible for inclusion in The mean volume of the planned
rank test was performed for the paired the TMJP group. Two were excluded DCIA flap was 30.71 ± 4.15 cm3 and
914 Modabber et al.

the mean volume of the DCIA flap

after the operation was 24.85 ±
6.14 cm3. The difference between these
measured volumes was not statistically
significant (P = 0.125). The difference
in the angle of the ventral osteotomy
between the planned and actual DCIA
flap was 9.86 ± 3.92°, while the differ­
ence in the angle of the dorsal os­
teotomy was 15.46 ± 10.32°. The
measured deviation between the height
of the actual DCIA flap and the
planned one was 1.58 ± 1.88 mm. The
translation in ventral to dorsal direc­
tion was 5.38 ± 5.51 mm.
The 3D comparison revealed a mean
deviation of 0.11 ± 0.04 mm between
the planned DCIA flap with TMJP and
the actual DCIA flap with TMJP. Of
the tested data points, 77.51% were
within one standard deviation. The 3D
distance analysis for one of the study
patients is shown in Fig. 3, while a
histogram of the deviations between the
measurement points for one of the pa­
tients is shown in Fig. 4.
Regarding the differences in the po­
sition of the planned and actual TMJP,
these were 0.56 ± 0.57 mm for the
height, 0.33 ± 0.24 mm for the ventral/
dorsal direction, and 1.18 ± 0.42 mm
for the medial/lateral direction.

Discussion
Fig. 2. Visualization of the measurements of the TMJ position between the equalization
planes. The postoperative model of the transplant is hidden for clarity. Reconstruction of the vertical dimen­
sion after resection of the condyle and a
Table 1. Characteristics of the study patients in the TMJP and control groupsa. hemimandibulectomy can be per­
TMJP group Control group formed in different ways. The mandible
n n can be reconstructed with an auto­
logous microvascular bone flap such as
Sex
Female 1 1
the DCIA flap7,8, and a total joint re­
Male 4 4 placement system or autologous trans­
Age (years) plant such as a costochondral graft can
< 40 1 0 be used9,10. While autologous grafts are
40–49 0 1 the preferred means of reconstruction
50–59 2 2 in children because of their capacity to
60–69 1 2 grow with the patient11, alloplastic de­
70–79 1 0 vices may be used in fully grown pa­
Diagnosis tients12. In a study comparing
MRONJ 2 1
alloplastic joints to the use of costo­
Osteomyelitis 1 2
Ameloblastoma 1 2 chondral grafts for TMJ reconstruc­
Keratocyst 1 0 tion, it was found that the frequency of
Time of reconstruction complications was comparable in the
Primary 4 4 two groups, but the number of further
Secondary 1 1 invasive operations required was three
Side of hemimandibulectomy times higher in the costochondral graft
Left 3 2 group13. For an autologous free trans­
Right 2 3 plant to work, certain prerequisites in
MRONJ, medication-related osteonecrosis of the jaw; TMJP, temporomandibular joint the transplant bed must be met, such as
prosthesis. good vascularization and ≤1 previous
a
TMJP group: virtually planned DCIA flap with TMJP; control group: virtually TMJ surgeries.14 For the patients in­
planned DCIA flap without TMJP. cluded in the present study, a large part
 Virtual surgery planning of stock TMJ prosthesis 915

Table 2. Measured values for mouth opening, laterotrusion, and midline deviation (mm) available permanent TMJ replacement
in the TMJP and control groupsa. systems consist of a condyle component
TMJP group Control group P-value and a fossa component to prevent skull
base erosion and dislocation of the
Mouth opening 36.6 ± 3.1 43.0 ± 1.6 0.024*
Laterotrusion to the resected side 0.8 ± 0.8 4.4 ± 1.1 0.008*
condyle. Therefore a fossa component
Midline deviation to the resected side 1.0 ± 1.0 3.4 ± 1.1 0.024* had to be used in any case.
The position of the stock TMJP on
TMJP, temporomandibular joint prosthesis.
* the DCIA flap was planned in house
Significant difference between the groups, P < 0.05 .
a
TMJP group: virtually planned DCIA flap with TMJP; control group: virtually using CAD software. If the functional
planned DCIA flap without TMJP. outcomes of patients reconstructed
with a virtually planned stock pros­
thesis are the same as those of patients
reconstructed with a patient-specific
custom TMJP, the latter would not be
necessary and so costs could be saved,
allowing resources to be diverted to
other parts of the healthcare system.
The advantages of using a computer-
planned stock TMJP over a commer­
cially available custom TMJP are nu­
merous. Stock prostheses are already
available in the hospital or can be de­
livered within a few days, while the
planning and manufacturing of custom
prostheses takes about 8 weeks. Thus,
this ready availability of stock pros­
theses with in-house computer-plan­
ning may lead to earlier treatment of
the patient. Furthermore, stock pros­
theses are not as expensive as custom
prostheses.
While alloplastic stock TMJ pros­
theses are normally inserted during the
operation according to the surgeon’s
intuition, virtual planning of the stock
prosthesis before the operation will
allow accurate placement of the pros­
thesis on the flap to provide optimal
function and outcomes. In addition,
placement during the computer plan­
ning can be performed not only by the
surgeon but also by other specialists.
Virtual planning thus leads to addi­
tional advantages for the stock pros­
thesis, closer to those of the custom
prosthesis. However, it is essential that
Fig. 3. Three-dimensional deviation analysis for one of the study patients. The scale on the in-house virtual plan is im­
the right shows the deviation in millimetres for each colour of the model. plemented precisely in the operating
theatre. In the present study, the accu­
racy of implementation was determined
of the jaw was resected. In such cases, All of the patients included in this by measuring the position and volume
the alloplastic TMJ replacement has a study were suffering from benign dis­ of the planned and actual DCIA flaps,
higher chance of healing than a free eases of the mandible, as shown in as well as the deviation of the TMJP on
graft, e.g. a costochondral graft, at­ Table 1. The condyle was completely the DCIA flap between the planned and
tached to the DCIA flap. Moreover, the affected in each case, and the kerato­ actual positions in different dimen­
use of an alloplastic joint eliminates the cyst and ameloblastoma extended into sions.
donor site morbidity resulting from the the soft tissue. Therefore, the resection The comparison of the volume of the
harvest of autologous grafts15. Al­ of the TMJ disc was necessary to pre­ DCIA flap showed that the actual
though there is controversy in the lit­ vent recurrences. For the reasons dis­ DCIA flaps were not significantly
erature regarding the type of cussed above, the vertical dimension smaller than the planned ones. The
reconstruction to perform, the use of was reconstructed using an alloplastic non-significant small volume loss that
TMJPs for reconstruction in adults has TMJ replacement system connected to occurred can be explained by the
been shown to lead to good out­ a DCIA flap (Fig. 5). To the authors’ shaping of the DCIA flap with a bur
comes16. knowledge, all of the currently after raising it with the cutting guide,
916 Modabber et al.

the scarring is too lax at this point, a

deviation may result.
In the 3D comparison, the deviation
between the planned and actual DCIA
flap was smaller in this study than in
the literature19, indicating that the im­
plementation of the computer planning
was clinically acceptable. However, the
missing scarring after the TMJ re­
construction led to sagging of the
complete lower jaw while the position
of the planned TMJP on the DCIA flap
was accurate.
The position of the TMJP on the
DCIA flap was displaced by approxi­
mately 1 mm in all three dimensions.
This minimal deviation was the result
of an effective virtual planning process
and successful transfer of the plan in
the operation theatre.
The evaluation of the functional
outcomes of the patients in this study
revealed that mouth opening in both
groups was comparable to the values
reported in the literature21,22, although
Fig. 4. Example histogram of one patient showing the measured points in the three-di­ mouth opening in the control group
mensional deviation analysis. The share of points in the range of a standard deviation are reconstructed without a TMJP was
shown as percentages. significantly higher than that in the
TMJP group. This finding is not sur­
and this volume loss is comparable to unstable in the present study patients. prising, as the movement of the lower
the values reported previously in the Stability in the position of the flap in­ jaw is less restricted without a TMJ.
literature17. The deviation between the creases as scar formation occurs Laterotrusion after opening the mouth
actual and planned positions of the around the TMJP; until the scar tissue and deviation of the midline were sig­
DCIA flap for translation in ventral to is strong enough to keep the mandible nificantly higher in the control group
dorsal dimension measured in this and the DCIA flap in place, greater without a TMJP than in the group with
study was slightly higher than those movement remains possible. Due to the computer-planned TMJP. These
reported in the literature, while the de­ sagging of the tissue, the position of the results show that the guidance of
viation in height was comparable to flap and the TMJP can alter from the movements was more controlled when
literature values18–20. In these previous planned position directly after surgery. a TMJP was inserted, and the values
studies, the mandibles were re­ To prevent this movement of the flap measured show that the computer
constructed with both condyles in and the TMJP, maxillomandibular planning produced good functional
place. Due to the resection and re­ fixation is applied. However, the max­ outcomes for the patients (Fig. 6).
placement of one condyle, as well as the illomandibular fixation must be opened For the study patients, a more stable
detachment of ligaments and muscles, to protect the healthy TMJ from da­ occlusion was observed in those for
the postoperative situation was more mage after a certain period of time. If whom in-house virtual planning of the
DCIA flap was combined with a stock
TMJ prosthesis when compared to
those left without a TMJ prosthesis. As
hypothesized, the in-house planning
and reconstruction with the stock TMJ
prosthesis led to significantly reduced
laterotrusion and deviation from the
midline. In the 3D analysis, the accu­
racy of the actual position of the TMJ
prosthesis was within approximately
1 mm of the planned position.
Therefore, this study found that per­
forming in-house computer-planning of
a microvascular bone flap in combina­
tion with a stock TMJ prosthesis was a
feasible and functional solution for
complicated cases, reducing the cost
Fig. 5. Panoramic X-ray of a patient after fitting of the DCIA flap with a virtually and time that would be required for a
planned TMJ prosthesis. custom commercial TMJ prosthesis.
 Virtual surgery planning of stock TMJ prosthesis 917

and alloplastic TMJ prosthesis. J

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