Extended Total Temporomandibular Joint Replacement with Occlusal Adjustments: Pitfalls, Patient-reported Outcomes, Subclassification, and a New Paradigm

CONTEXT: Alloplastic temporomandibular joint (TMJ) replacement is a treatment strategy for segmental mandibular defects with occlusal abnormalities. AIMS: To describe our experience with extended total TMJ replacement (eTMJR) by reporting operative obstacles, complications, and patient-reported outcomes, as well as to suggest a subclassification system and paradigm shift. SETTING AND DESIGN: University hospital and private clinic; case series with retrospective follow-up. METHODS AND MATERIALS: Five patients (6 eTMJRs) were followed for more than 1 year after surgery. Patient-reported outcomes were assessed using FACE-Q™ “Satisfaction with Outcome” questionnaires (sum and corresponding transformed Rasch scores). STATISTICAL ANALYSIS: Descriptive analyses were performed. RESULTS: Problems were related to contralateral mandibular osteotomy healing (if performed), keying the prosthetic condyle into the fossa component, intra- and postoperative prosthetic lag, and intraoperative proper establishment of the occlusion when unilateral replacement was performed. Patients reported high satisfaction with the outcome, with a mean Rasch score of 89.2/100. CONCLUSIONS: Unilateral eTMJR obstacles related to three-dimensional rotational repositioning of the remaining mandible. We suggest a paradigm shift, considering primary alloplastic replacement instead of microvascular osseous transplantation for reconstruction when radiotherapy is not required. This can avoid donor site morbidity and long reconstructive surgery. An autologous osseous transplant is still available in case of implant failure. A subclassification system is proposed for eTMJR, which accounts for contour corrections, occlusal adjustments, and simultaneous contralateral mandibular osteotomy.