Use of Vascularized Myo-Osseous Fibula Free Flap to Reconstruct a Hemimandibular Defect With a Concomitant Skull Defect Arising From Stock Condylar Prosthesis Displacement Into the Middle Cranial Fossa

Functional reconstruction of the temporomandibular joint (TMJ) is a controversial topic among oral and maxillofacial surgeons; this controversy becomes more complicated when one dives into the dilemma of the ideal reconstructive modality. TMJ defects might result from various etiologies, such as blunt or penetrating traumatic injuries, advanced degenerative joint disease, or various pathologic conditions, including benign and malignant conditions, that might arise from the TMJ or adjacent tissues. Reconstruction of the TMJ is vital because of its essential function in mastication, articulation, speech, and facial esthetics and symmetry. In the pediatric population, the TMJ acts as a growth center. TMJ reconstructive surgery might be influenced by various factors that can steer the surgeon toward adopting a specific reconstructive modality. These factors can be classified into preoperative factors that include the overall general health of the patient, expectations, and socioeconomic status that might be an obstacle in using custom-made solutions. The surgeon's experience, level of comfort, and training are crucial influencing factors. TMJ reconstructive options consist of autogenous grafts or alloplastic options. Autogenous grafts encompass 2 broad subcategories. The first is the vascularized option, and a good example is the vascularized fibula free flap. The second subcategory includes nonvascularized grafts, such as costochondral grafts and sternoclavicular grafts. Alloplastic grafts include various TMJ stock joints or custom-made patient-specific prostheses and stock condylar prostheses. The goals of TMJ reconstruction are to establish a pain-free normal range of mouth opening, stable occlusion, and absence of facial deformity. Complication rates in TMJ surgery are low and include surgical infection, nerve injury, failure or fracture of the prosthesis, or injury to adjacent structures. This report presents a case of a stock condylar prosthesis displaced into the middle cranial fossa, which was managed with a 2-stage approach of removing the displaced prosthesis and then reconstruction with a fibula vascularized free flap and a simultaneous contralateral sagittal split osteotomy.