Total joint replacement with the stock Biomet system in adult hemifacial microsomia without glenoid fossa: A case report and literature review

Total joint replacement with the stock Biomet system in adult hemifacial microsomia without glenoid fossa: A case report and literature review | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Total joint replacement with the stock Biomet system in adult hemifacial microsomia without glenoid fossa: A case report and literature review Kang Hee Yu, Jeong Joon Han, Soon Jung Hwang This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7056467/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 15 Oct, 2025 Read the published version in Maxillofacial Plastic and Reconstructive Surgery → Version 1 posted 16 You are reading this latest preprint version Abstract Background : In patients with hemifacial microsomia accompanied by mandibular fossa deficiency and severe atrophy of the mandibular ramus, customized total joint replacement (TJR) is commonly used to restore masticatory and joint function and improve facial asymmetry. However, in countries where customized TJR is not approved, or for patients for whom the cost is prohibitive, a stock TJR system must be considered. In cases with a severely medially inclined frontal ramal angle and a lack of supporting bone for the fossa component, using a stock TJR poses significant technical challenges. Case presentation : This case report describes the use of autogenous bone grafting to overcome these limitations. An 18-year-old male with HFM type IIB on the left side received staged procedures, including bone grafting between mandibular proximal and distal segments to increase the frontal ramal angle, autogenous reconstruction of the mandibular fossa to enable fixation of the TJR fossa component, and orthognathic surgery. Conclusions : Successful functional and esthetic outcomes were achieved, with stable maintenance of a stock Biomet TJR over a seven-year period. Hemifacial microsomia Zygomatic arch absence Glenoid fossa reconstruction Autologous bone graft Stock total joint replacement Frontal ramal angle Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 1. Background Hemifacial microsomia (HFM) is the most common congenital disorder of the face after cleft lip and palate [ 1 ]. The cause of HFM remains unknown. The most widely used classification system is Kaban’s modification of the Pruzansky classification system [ 2 ]. In severe forms, such as type IIB (condylar dysplasia or absence of the condyle with a flat or absent glenoid fossa) and type III (complete absence of the ramus and fossa), temporomandibular joint (TMJ) function and facial symmetry are severely compromised. In patients with HFM, functional and aesthetic improvements can be achieved through mandibular alloplastic joint reconstruction. However, in cases with type IIB or III, where the zygomatic arch is absent and ramus is severely displaced medially due to ramal dysplasia, a stock total joint replacement (TJR) system cannot be applied because fixation of the fossa component of the alloplastic joint is not feasible and correction of mandibular asymmetry in terms of a symmetrical frontal ramal angle is not possible. Reconstruction of a substantial glenoid fossa with bone grafts presents a significant challenge. Additionally, due to markedly insufficient thickness and severe displacement with inadequate lateral inclination of the mandibular body and ramus in HFM patients, it is difficult to position the alloplastic joint to closely match the frontal ramal angle of the non-affected side. Severe mandibular asymmetry remains after orthognathic surgery because the height and volume of the mandibular body on the affected side are smaller compared to those on the non-affected side [ 3 ]. To overcome those limitations, customized TJR or extended customized TJR has been applied and successful results have been reported [ 4 , 5 ]. However, there are countries where these types of TJR systems are not available to patients, because they are not approved by the national Food and Drug Administration (FDA). Moreover, the high cost of these systems is a great limitation for the application for many patients, especially when not covered by medical insurance. In this report, we present a surgical strategy to overcome these limitations. Autologous bone grafting was performed to reconstruct the area required for fixation of the fossa component, which was followed by successful TJR with a stock Biomet system (Zimmer Biomet Holdings®, Warsaw, U.S.). Furthermore, on the affected side, a sagittal split ramus osteotomy(SSRO) was carried out, and an iliac bone graft was interposed between the proximal and distal segments to recreate a frontal ramal angle similar to that of the non-affected side. Through this approach, we were able to achieve not only functional rehabilitation of TMJ but also significant aesthetic improvement, and the TJR was successfully maintained over a period of seven years. 2. Case presentation This study was approved by the Institutional Review Board of Seoul National University Dental Hospital (ERI 25024). An 18-year-old male with HFM type IIB on the left side visited for consultation regarding TMJ reconstruction and correction of mandibular asymmetry. He was previously treated at another hospital with iliac bone graft for augmentation of left mandibular body and rib cartilage graft for reconstruction of left ear. The grafted iliac bone was nearly completely resorbed. Problem lists of the patient on the left facial side were absence of glenoid fossa and posterior zygomatic arch, absence of condyle, atrophied short mandibular body, severe maxillary canting, thin mandibular ascending ramus, small frontal ramal inclination (medially inclined ramus), and mandibular retrognathism with asymmetry (Fig. 1 ). The stepwise surgical procedures for the improvement of those problems were as follows. Distraction osteogenesis (DO) of the left maxilla via Le Fort I osteotomy and of the mandible by unilateral SSRO for the correction of maxillary and mandibular canting on the left side was conducted. After Le Fort I osteotomy, a thin 2-hole miniplate was installed on the zygomaticomaxillary buttress on the right side, which acted as a rotation center during canting correction by DO, and a DO device was installed on the left maxilla (Fig. 2 a). After mandibular osteotomy with SSRO on left mandible, intermaxillary fixation was done and the planned distraction movement of left maxilla and mandibular distal segment was tested. One week after surgery, DO was started at 1mm per day for seven days, until maxillary canting was corrected (total 7mm DO) (Fig. 2 b). Six months after the first surgery, autogenous bone grafting was performed for the correction of the thin and medially inclined left mandibular ascending ramus and the absence of the glenoid fossa on the left side. Unilateral SSRO was performed and an autogenous iliac bone graft was positioned between the proximal and distal segments to increase the ramal thickness and decrease the medial inclination of the left mandibular ramus, which enabled installation of the mandibular part of the TJR with adequate frontal ramal inclination and mandibular symmetry in the frontal view (Fig. 3 a ~ 3e). Because of the absence of the mandibular fossa (Fig. 3 f), it was necessary to reconstruct a horizontally flat bony structure on the temporal bone for installation of the fossa part of TJR. Ramal bone was harvested from the right side, and three pieces of ramal bone were layered and fixed in a pyramidal form with a mini screw to adapt to the temporal slope. Then, it was stabilized with two mid-plates on the temporal bone. The dead space between the bone block and temporal bone was filled with an alloplastic bone substitute soaked with 0.5 cc recombinant human bone morphogenetic protein 2 (rhBMP-2) (Novosis®Dent, CG Bio, Seoul, Republic of Korea) (Fig. 3 g). Eight months after the second surgery, transplanted autogenous bone grafts at the left mandible and left temporal bone were well fused and stabilized. Orthognathic surgery with Le Fort I osteotomy and unilateral SSRO on the right side, with genioplasty and TJR with a stock Biomet system on the left side, was performed for the reconstruction of the left TMJ and the correction of mandibular retrognathism with asymmetry (Fig. 4 ~ 5). Plate removal and mandibuloplasty, including genioplasty, right angle reduction, and bone graft for the correction of residual asymmetry, were performed five months following the third surgical procedure (Fig. 6 a). Maxillary canting was successfully corrected by 7mm DO. Maxillary and mandibular length were well elongated as expected. However, the left mandibular proximal segment lacked joint structures, including the capsule and ligaments, thus providing insufficient resistance against simultaneous downward movement of the distal segment during DO. It moved downward together with the distal segment during DO, which was evident by the absence of a bone step at the antegonial notch. In the second surgery, thin and medially positioned left mandibular ramus was changed to a thicker and symmetrical form, thus providing adequate structure for TJR. In addition, the osseous structure for the installation of the fossa component of the stock Biomet TJR was successfully reconstructed by the ramal bone graft combined with an alloplastic bone substitute soaked with rhBMP-2. Thanks to these preparatory surgical treatments, the main operations with TJR and orthognathic surgery could be conducted with successful functional and aesthetic outcomes. TMJ function was normalized by TJR, and skeletal malocclusion with facial asymmetry could be easily and effectively corrected according to the surgical plan. After the last surgery, including facial contouring with additional genioplasty, right angle reduction, and bone graft, balanced facial symmetry was achieved (Fig. 6 ), and stable occlusion was maintained during postoperative orthodontic treatment. The TJR was well maintained for seven years. 3. Discussion The surgical needs in patients with HFM depend entirely on the type and severity of the facial abnormalities. Surgical interventions are designed to restore the patient’s craniofacial form and function and must account for the expected facial growth pattern, timing of dental eruption, schedules for school and extracurricular activities, along with other psychosocial factors. In general, surgical treatments for HFM include bone grafting, free flaps, DO, TJR, and orthognathic surgery [ 6 ]. Treatment recommendations for the type II mandible differ based on the distinction between the IIA and IIB subgroups. The IIA subgroup requires vertical lengthening of the mandible, typically with an osteotomy and interposed bone graft, performed after skeletal maturity. The IIB subgroup is classically treated with a costochondral bone graft of the ramus and condyle with reconstruction of the glenoid fossa. Treatment of the type III mandible is similar to that of the IIB mandible [ 7 ]. In our present study with HFM IIB subgroup, an intersegmental autogenous bone graft between the proximal and distal segments after SSRO was performed, which resulted in improvement of mandibular asymmetry. Not only was the thin and medially positioned left mandibular ramus changed to a thicker and symmetrical form, but also it enabled adequate frontal angulation of the mandibular part of the TJR. A costochondral graft is common for reconstruction of the TMJ but has unpredictable growth and resorption. Lack of regional soft tissue and decreased vascularity likely contribute to the resorption of these grafts. Therefore, microsurgical techniques using fibular osteocutaneous free flaps for the treatment of the type III mandible have been introduced. However, this technique does not address the soft tissue deficiency that is common in HFM. DO of the mandible was introduced in an attempt to address these deficiencies. However, the effectiveness of DO decreases as the severity of HFM increases. Lengthening of small, malpositioned bony segments through DO results in an elongated structure that remains anatomically misaligned. In cases of severe HFM, the utility of DO appears to be restricted to highly specific indications [ 8 ]. TMJ and glenoid fossa can be reconstructed with alloplastic materials in cases with large defects which would make the procedure difficult with autogenous bone grafting [ 9 ]. Long-term follow-up of the effects of the Christensen Fossa Eminence Prosthesis on the mandibular condyle has not been widely reported. In a study by Chase et al., treatment with a fossa eminence prosthesis resulted in significant functional improvement and pain reduction [ 10 ]. The patients in their study had diagnoses of osteoarthritis, rheumatoid arthritis, or internal derangement associated with their TMJ. Securing an autogenous glenoid fossa to an abnormally sloped, canted temporal bone lacking a bony flange is particularly difficult. Additionally, recreating a broad, stable articular surface using autogenous materials remains technically demanding [ 11 ]. Reconstruction of the glenoid fossa using costochondral grafts has been explored in previous studies, which presented a technique of immediate reconstruction of the petrous portion of the temporal bone and of the mandible [ 12 ]. Richter et al. reconstructed the cranial base and condyle during the same operation using calvarial bone [ 13 ]. The reconstructed cranial base must protect the dura and brain from the significant forces generated by the masticatory muscles, for which calvarial bone is particularly suitable due to its high density and lower resorption rate compared to iliac bone grafts [ 14 ]. In addition, as it is composed of cortical bone, calvarial bone provides firm anchorage for screw fixation, allowing immediate stability that cannot be achieved with costochondral grafts. In our present report, flat bone structure at the temporal bone for the installation of fossa part of TJR could be easily reconstructed by mandibular ramal bone and alloplastic bone substitute soaked with rhBMP-2. Given the increasing use of custom-made extended TMJ prostheses and the absence of a standardized classification, a classification system based on mandibular and fossa extension patterns was proposed. A two-part classification system for extended TJR was developed to categorize prosthetic designs according to mandibular and skull base involvement, with the goal of enhancing clarity in surgical planning and design specification [ 15 ]. 4. Conclusion Patients with HFM without a condyle and glenoid fossa of the temporal bone have severe limitations for the use of the stock system of TJR. Even though the extended custom system of TJR is increasingly applied for such types, this system is not available for many patients. In the present report, the osseous structure for the installation of the fossa component of the stock Biomet TJR was successfully reconstruction by the ramal bone graft combined with alloplastic bone substitute soaked with rhBMP-2, and TJR could be well maintained for a long time. Moreover, intersegmental autogenous bone graft at the mandibular ascending ramus after SSRO enabled adequate frontal angulation of the mandibular part of the TJR with the improvement of mandibular asymmetry. Abbreviations TJR Total joint replacement HFM Hemifacial microsomia TMJ Temporomandibular joint FDA Food and Drug Administration SSRO Sagittal split ramus osteotomy DO Distraction osteogenesis Declarations Consent for publication Informed consent was obtained from the patient for the publication of this case report. Funding No funding was received. Author Contribution KH Yu was responsible for data collection, investigation, visualization, and writing – original draft. JJ Han contributed to resources and writing – review. SJ Hwang was involved in methodology, project administration, supervision, validation, and writing – review and editing. References Cascone P, Vellone V, Ramieri V, Basile E, Tarsitano A, et al. (2018) Reconstruction of the Adult Hemifacial Microsomia Patient with Temporomandibular Joint Total Joint Prosthesis and Orthognathic Surgery. Case Rep Surg 2018: 2968983. Birgfeld C B, Heike C (2012) Craniofacial microsomia. Semin Plast Surg 26(2): 91-104. López D F, Acosta D M, Rivera D A, Mejía C M (2022) Hemifacial microsomia: treatment alternatives-a systematic review of literature. J Clin Pediatr Dent 46(5): 15-30. Subash P, V V P, Iyer S, Nerurkar S, Krishnadas A, et al. (2023) Concomitant Microvascular Aided Extended Temporo-Mandibular Joint Replacement (ME-TJR) and Stock Temporo-Mandibular Joint Replacement (MS-TJR) During Mandibular Reconstruction. J Maxillofac Oral Surg 22(Suppl 1): 110-117. Briceno W X, Milkovich J, El-Rabbany M, Caminiti M F, Psutka D J (2022) Reconstruction of Large Defects Using Extended Temporomandibular Joint Patient-Matched Prostheses. J Oral Maxillofac Surg 80(6): 1018-1032. Prada Madrid J R, Montealegre G, Gomez V (2010) A New Classification Based on the Kaban's Modification for Surgical Management of Craniofacial Microsomia. Craniomaxillofac Trauma Reconstr 3(1): 1-7. Zanakis N S, Gavakos K, Faippea M, Karamanos A, Zotalis N (2009) Application of custom-made TMJ prosthesis in hemifacial microsomia. Int J Oral Maxillofac Surg 38(9): 988-992. Wolford L M, Perez D E (2015) Surgical management of congenital deformities with temporomandibular joint malformation. Oral Maxillofac Surg Clin North Am 27(1): 137-154. Tawfilis A R, Chappell E T, Farhood V W (2002) Alloplastic reconstruction of a temporal bone and glenoid fossa defect. J Oral Maxillofac Surg 60(9): 1079-1082. Chase D C, Hudson J W, Gerard D A, Russell R, Chambers K, et al. (1995) The Christensen prosthesis. A retrospective clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80(3): 273-278. Polley J W, Girotto J A, Fahrenkopf M P, Dietze-Fiedler M L, Kelley J P, et al. (2019) Salvage or Solution: Alloplastic Reconstruction in Hemifacial Microsomia. Cleft Palate Craniofac J 56(7): 896-901. Hirota Y, Ueda K, Katayama M, Otsuki Y (2018) Functional Temporomandibular Joint Reconstruction in Costochondral Grafting of Micrognathia. Plast Reconstr Surg Glob Open 6(10): e1925. Richter M, Dulguerov P, Pittet B, Becker M (1997) Immediate function of temporomandibular joint after total resection and reconstruction. J Craniofac Surg 8(5): 383-390. Movahed R, Pinto L P, Morales-Ryan C, Allen W R, Wolford L M (2013) Application of cranial bone grafts for reconstruction of maxillofacial deformities. Proc (Bayl Univ Med Cent) 26(3): 252-255. Elledge R, Mercuri L G, Speculand B (2018) Extended total temporomandibular joint replacements: a classification system. Br J Oral Maxillofac Surg 56(7): 578-581. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 15 Oct, 2025 Read the published version in Maxillofacial Plastic and Reconstructive Surgery → Version 1 posted Editorial decision: Revision requested 24 Jul, 2025 Reviews received at journal 24 Jul, 2025 Reviews received at journal 23 Jul, 2025 Reviewers agreed at journal 21 Jul, 2025 Reviews received at journal 20 Jul, 2025 Reviewers agreed at journal 20 Jul, 2025 Reviews received at journal 17 Jul, 2025 Reviewers agreed at journal 16 Jul, 2025 Reviews received at journal 16 Jul, 2025 Reviewers agreed at journal 11 Jul, 2025 Reviewers agreed at journal 11 Jul, 2025 Reviewers agreed at journal 10 Jul, 2025 Reviewers invited by journal 09 Jul, 2025 Editor assigned by journal 08 Jul, 2025 Submission checks completed at journal 08 Jul, 2025 First submitted to journal 06 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7056467","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":484300804,"identity":"6a2e524d-490e-4f72-9a2c-73e83b16e268","order_by":0,"name":"Kang Hee Yu","email":"","orcid":"","institution":"Chungbuk National University","correspondingAuthor":false,"prefix":"","firstName":"Kang","middleName":"Hee","lastName":"Yu","suffix":""},{"id":484300805,"identity":"20135c51-29e6-4668-b9a0-f6850990ffea","order_by":1,"name":"Jeong Joon Han","email":"","orcid":"","institution":"Seoul National University Dental Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jeong","middleName":"Joon","lastName":"Han","suffix":""},{"id":484300806,"identity":"d9feacf9-ba22-4cef-b49c-a5654142e93c","order_by":2,"name":"Soon Jung Hwang","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA6ElEQVRIiWNgGAWjYJACZjApf/jgAyDFw0e8Fgm2ZAOQFjYStPCYSYBoglrk25uPPS5ss8uTj+4xq/yaYyfDxsD88NENPFoMzhxLN57ZllxseOdY2W3ZbclAh7EZG+fg0yKRYybNu405cWND8rbbktuYgVp42KTxaZGfAdZSD9SSYFYsua2esBaGG2AthxPnS6SYMX7cdpiwFqBf0qR5/x1P3MBzLFmacdtxHjZmAn4BhZg0z5nqxPntzQc//txWbc/P3vzwMV6Hwa07AIwgHhCLmRjlYOsaGBgYfxCrehSMglEwCkYUAABcmUXBxor3uwAAAABJRU5ErkJggg==","orcid":"","institution":"HSJ Dental Clinic for Oral and Maxillofacial Surgery","correspondingAuthor":true,"prefix":"","firstName":"Soon","middleName":"Jung","lastName":"Hwang","suffix":""}],"badges":[],"createdAt":"2025-07-06 07:53:09","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7056467/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7056467/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s40902-025-00478-5","type":"published","date":"2025-10-15T15:57:15+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":86758144,"identity":"ba4a040d-6ef3-4625-b674-867e3089f003","added_by":"auto","created_at":"2025-07-15 09:49:25","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":397708,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRadiographs on initial visit\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea) panoramic view b) frontal and lateral views of 3D CT\u003c/p\u003e","description":"","filename":"Slide1.png","url":"https://assets-eu.researchsquare.com/files/rs-7056467/v1/7f5e31d1789b19dbe7b45eb1.png"},{"id":86758151,"identity":"68f3b534-1fdf-433e-9f7e-ce646ee9006c","added_by":"auto","created_at":"2025-07-15 09:49:25","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":316488,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePanoramic view after the first surgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea) immediate after surgery for DO device installation at maxilla and mandibular SSRO on the left side \u0026nbsp;b) three weeks after DO\u003c/p\u003e","description":"","filename":"Slide2.png","url":"https://assets-eu.researchsquare.com/files/rs-7056467/v1/3681d8b25c019397271f776e.png"},{"id":86758146,"identity":"f97b03ef-7d27-46f4-bf24-5bc7c3782d69","added_by":"auto","created_at":"2025-07-15 09:49:25","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":822095,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eCT views before and after the second surgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea) axial cut of CT before and after autogenous intersegmental bone graft after SSRO at left mandibular ramus, b) simulation SSRO on the left side (red line – symmetrical frontal ramal inclination on right and left side), c) simulation of lateral swing movement of the left proximal segment after SSRO, d) simulation of intersegmental bone graft, e) 3D CT image after the second surgery, f) initial status of temporal bone; absence of glenoid fossa in 3D CT (left) and coronal cut of CT (right), g) reconstructed flat osseous structure on the temporal slope by ramal bone graft for the installation of mandibular fossa part of stock Biomet TJR in 3D CT (left) and coronal cut of CT (right).\u003c/p\u003e","description":"","filename":"Slide3.png","url":"https://assets-eu.researchsquare.com/files/rs-7056467/v1/37184f2dcf78fa78aa471002.png"},{"id":86758150,"identity":"cf664a2e-0f46-49d6-9a1f-6965c3eebd66","added_by":"auto","created_at":"2025-07-15 09:49:25","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":386165,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eRadiographs after TJR and two jaw surgery in the third surgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea) panoramic view: TJR on the left side, b) coronal cut of CT at TMJ. Installed fossa part of TJR on the well regenerated bone graft at temporal bone and mandibular part of TJR, c) lateral cephalogram before two jaw surgery and TJR, d) lateral cephalogram after two jaw surgery and TJR.\u003c/p\u003e","description":"","filename":"Slide4.png","url":"https://assets-eu.researchsquare.com/files/rs-7056467/v1/ba9cd11ca3a6619d12f66644.png"},{"id":86758147,"identity":"5185bcf3-d463-44c4-b9db-0d9a0d9933dc","added_by":"auto","created_at":"2025-07-15 09:49:25","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":486586,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eFrontal view of 3D CT before and after two jaw surgery and TJR\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea) initial visit, b) six months after two jaw surgery and TJR\u003c/p\u003e","description":"","filename":"Slide5.png","url":"https://assets-eu.researchsquare.com/files/rs-7056467/v1/5e9aa93561b004c34e4cff07.png"},{"id":86759226,"identity":"24b63765-239a-464e-9767-6cb5f93ea316","added_by":"auto","created_at":"2025-07-15 09:57:25","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":310208,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePanorama views after mandibular contouring surgery in the fourth surgery\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ea) immediate after the fourth surgery, b) three months after the fourth surgery\u003c/p\u003e","description":"","filename":"Slide6.png","url":"https://assets-eu.researchsquare.com/files/rs-7056467/v1/23aa2a99505d82fe6ec0a4d0.png"},{"id":93956194,"identity":"01d22ccf-c00b-4656-b98b-28df6e0ac5e0","added_by":"auto","created_at":"2025-10-20 16:11:26","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":4035812,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7056467/v1/af5ddbf2-85cc-4ca8-8edd-fb04d5060663.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Total joint replacement with the stock Biomet system in adult hemifacial microsomia without glenoid fossa: A case report and literature review","fulltext":[{"header":"1. Background","content":"\u003cp\u003eHemifacial microsomia (HFM) is the most common congenital disorder of the face after cleft lip and palate [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The cause of HFM remains unknown. The most widely used classification system is Kaban\u0026rsquo;s modification of the Pruzansky classification system [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. In severe forms, such as type IIB (condylar dysplasia or absence of the condyle with a flat or absent glenoid fossa) and type III (complete absence of the ramus and fossa), temporomandibular joint (TMJ) function and facial symmetry are severely compromised.\u003c/p\u003e\u003cp\u003eIn patients with HFM, functional and aesthetic improvements can be achieved through mandibular alloplastic joint reconstruction. However, in cases with type IIB or III, where the zygomatic arch is absent and ramus is severely displaced medially due to ramal dysplasia, a stock total joint replacement (TJR) system cannot be applied because fixation of the fossa component of the alloplastic joint is not feasible and correction of mandibular asymmetry in terms of a symmetrical frontal ramal angle is not possible. Reconstruction of a substantial glenoid fossa with bone grafts presents a significant challenge. Additionally, due to markedly insufficient thickness and severe displacement with inadequate lateral inclination of the mandibular body and ramus in HFM patients, it is difficult to position the alloplastic joint to closely match the frontal ramal angle of the non-affected side. Severe mandibular asymmetry remains after orthognathic surgery because the height and volume of the mandibular body on the affected side are smaller compared to those on the non-affected side [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTo overcome those limitations, customized TJR or extended customized TJR has been applied and successful results have been reported [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. However, there are countries where these types of TJR systems are not available to patients, because they are not approved by the national Food and Drug Administration (FDA). Moreover, the high cost of these systems is a great limitation for the application for many patients, especially when not covered by medical insurance.\u003c/p\u003e\u003cp\u003eIn this report, we present a surgical strategy to overcome these limitations. Autologous bone grafting was performed to reconstruct the area required for fixation of the fossa component, which was followed by successful TJR with a stock Biomet system (Zimmer Biomet Holdings\u0026reg;, Warsaw, U.S.). Furthermore, on the affected side, a sagittal split ramus osteotomy(SSRO) was carried out, and an iliac bone graft was interposed between the proximal and distal segments to recreate a frontal ramal angle similar to that of the non-affected side. Through this approach, we were able to achieve not only functional rehabilitation of TMJ but also significant aesthetic improvement, and the TJR was successfully maintained over a period of seven years.\u003c/p\u003e"},{"header":"2. Case presentation","content":"\u003cp\u003eThis study was approved by the Institutional Review Board of Seoul National University Dental Hospital (ERI 25024). An 18-year-old male with HFM type IIB on the left side visited for consultation regarding TMJ reconstruction and correction of mandibular asymmetry. He was previously treated at another hospital with iliac bone graft for augmentation of left mandibular body and rib cartilage graft for reconstruction of left ear. The grafted iliac bone was nearly completely resorbed. Problem lists of the patient on the left facial side were absence of glenoid fossa and posterior zygomatic arch, absence of condyle, atrophied short mandibular body, severe maxillary canting, thin mandibular ascending ramus, small frontal ramal inclination (medially inclined ramus), and mandibular retrognathism with asymmetry (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The stepwise surgical procedures for the improvement of those problems were as follows.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eDistraction osteogenesis (DO) of the left maxilla via Le Fort I osteotomy and of the mandible by unilateral SSRO for the correction of maxillary and mandibular canting on the left side was conducted. After Le Fort I osteotomy, a thin 2-hole miniplate was installed on the zygomaticomaxillary buttress on the right side, which acted as a rotation center during canting correction by DO, and a DO device was installed on the left maxilla (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003ea). After mandibular osteotomy with SSRO on left mandible, intermaxillary fixation was done and the planned distraction movement of left maxilla and mandibular distal segment was tested. One week after surgery, DO was started at 1mm per day for seven days, until maxillary canting was corrected (total 7mm DO) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eb).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eSix months after the first surgery, autogenous bone grafting was performed for the correction of the thin and medially inclined left mandibular ascending ramus and the absence of the glenoid fossa on the left side. Unilateral SSRO was performed and an autogenous iliac bone graft was positioned between the proximal and distal segments to increase the ramal thickness and decrease the medial inclination of the left mandibular ramus, which enabled installation of the mandibular part of the TJR with adequate frontal ramal inclination and mandibular symmetry in the frontal view (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea\u0026thinsp;~\u0026thinsp;3e). Because of the absence of the mandibular fossa (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ef), it was necessary to reconstruct a horizontally flat bony structure on the temporal bone for installation of the fossa part of TJR. Ramal bone was harvested from the right side, and three pieces of ramal bone were layered and fixed in a pyramidal form with a mini screw to adapt to the temporal slope. Then, it was stabilized with two mid-plates on the temporal bone. The dead space between the bone block and temporal bone was filled with an alloplastic bone substitute soaked with 0.5 cc recombinant human bone morphogenetic protein 2 (rhBMP-2) (Novosis\u0026reg;Dent, CG Bio, Seoul, Republic of Korea) (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eg).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eEight months after the second surgery, transplanted autogenous bone grafts at the left mandible and left temporal bone were well fused and stabilized. Orthognathic surgery with Le Fort I osteotomy and unilateral SSRO on the right side, with genioplasty and TJR with a stock Biomet system on the left side, was performed for the reconstruction of the left TMJ and the correction of mandibular retrognathism with asymmetry (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e\u0026thinsp;~\u0026thinsp;5). Plate removal and mandibuloplasty, including genioplasty, right angle reduction, and bone graft for the correction of residual asymmetry, were performed five months following the third surgical procedure (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003ea).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eMaxillary canting was successfully corrected by 7mm DO. Maxillary and mandibular length were well elongated as expected. However, the left mandibular proximal segment lacked joint structures, including the capsule and ligaments, thus providing insufficient resistance against simultaneous downward movement of the distal segment during DO. It moved downward together with the distal segment during DO, which was evident by the absence of a bone step at the antegonial notch. In the second surgery, thin and medially positioned left mandibular ramus was changed to a thicker and symmetrical form, thus providing adequate structure for TJR. In addition, the osseous structure for the installation of the fossa component of the stock Biomet TJR was successfully reconstructed by the ramal bone graft combined with an alloplastic bone substitute soaked with rhBMP-2. Thanks to these preparatory surgical treatments, the main operations with TJR and orthognathic surgery could be conducted with successful functional and aesthetic outcomes. TMJ function was normalized by TJR, and skeletal malocclusion with facial asymmetry could be easily and effectively corrected according to the surgical plan. After the last surgery, including facial contouring with additional genioplasty, right angle reduction, and bone graft, balanced facial symmetry was achieved (Fig.\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e), and stable occlusion was maintained during postoperative orthodontic treatment. The TJR was well maintained for seven years.\u003c/p\u003e"},{"header":"3. Discussion","content":"\u003cp\u003eThe surgical needs in patients with HFM depend entirely on the type and severity of the facial abnormalities. Surgical interventions are designed to restore the patient\u0026rsquo;s craniofacial form and function and must account for the expected facial growth pattern, timing of dental eruption, schedules for school and extracurricular activities, along with other psychosocial factors. In general, surgical treatments for HFM include bone grafting, free flaps, DO, TJR, and orthognathic surgery [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTreatment recommendations for the type II mandible differ based on the distinction between the IIA and IIB subgroups. The IIA subgroup requires vertical lengthening of the mandible, typically with an osteotomy and interposed bone graft, performed after skeletal maturity. The IIB subgroup is classically treated with a costochondral bone graft of the ramus and condyle with reconstruction of the glenoid fossa. Treatment of the type III mandible is similar to that of the IIB mandible [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. In our present study with HFM IIB subgroup, an intersegmental autogenous bone graft between the proximal and distal segments after SSRO was performed, which resulted in improvement of mandibular asymmetry. Not only was the thin and medially positioned left mandibular ramus changed to a thicker and symmetrical form, but also it enabled adequate frontal angulation of the mandibular part of the TJR.\u003c/p\u003e\u003cp\u003eA costochondral graft is common for reconstruction of the TMJ but has unpredictable growth and resorption. Lack of regional soft tissue and decreased vascularity likely contribute to the resorption of these grafts. Therefore, microsurgical techniques using fibular osteocutaneous free flaps for the treatment of the type III mandible have been introduced. However, this technique does not address the soft tissue deficiency that is common in HFM. DO of the mandible was introduced in an attempt to address these deficiencies. However, the effectiveness of DO decreases as the severity of HFM increases. Lengthening of small, malpositioned bony segments through DO results in an elongated structure that remains anatomically misaligned. In cases of severe HFM, the utility of DO appears to be restricted to highly specific indications [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eTMJ and glenoid fossa can be reconstructed with alloplastic materials in cases with large defects which would make the procedure difficult with autogenous bone grafting [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Long-term follow-up of the effects of the Christensen Fossa Eminence Prosthesis on the mandibular condyle has not been widely reported. In a study by Chase et al., treatment with a fossa eminence prosthesis resulted in significant functional improvement and pain reduction [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. The patients in their study had diagnoses of osteoarthritis, rheumatoid arthritis, or internal derangement associated with their TMJ.\u003c/p\u003e\u003cp\u003eSecuring an autogenous glenoid fossa to an abnormally sloped, canted temporal bone lacking a bony flange is particularly difficult. Additionally, recreating a broad, stable articular surface using autogenous materials remains technically demanding [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. Reconstruction of the glenoid fossa using costochondral grafts has been explored in previous studies, which presented a technique of immediate reconstruction of the petrous portion of the temporal bone and of the mandible [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Richter et al. reconstructed the cranial base and condyle during the same operation using calvarial bone [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. The reconstructed cranial base must protect the dura and brain from the significant forces generated by the masticatory muscles, for which calvarial bone is particularly suitable due to its high density and lower resorption rate compared to iliac bone grafts [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In addition, as it is composed of cortical bone, calvarial bone provides firm anchorage for screw fixation, allowing immediate stability that cannot be achieved with costochondral grafts. In our present report, flat bone structure at the temporal bone for the installation of fossa part of TJR could be easily reconstructed by mandibular ramal bone and alloplastic bone substitute soaked with rhBMP-2.\u003c/p\u003e\u003cp\u003eGiven the increasing use of custom-made extended TMJ prostheses and the absence of a standardized classification, a classification system based on mandibular and fossa extension patterns was proposed. A two-part classification system for extended TJR was developed to categorize prosthetic designs according to mandibular and skull base involvement, with the goal of enhancing clarity in surgical planning and design specification [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e"},{"header":"4. Conclusion","content":"\u003cp\u003ePatients with HFM without a condyle and glenoid fossa of the temporal bone have severe limitations for the use of the stock system of TJR. Even though the extended custom system of TJR is increasingly applied for such types, this system is not available for many patients. In the present report, the osseous structure for the installation of the fossa component of the stock Biomet TJR was successfully reconstruction by the ramal bone graft combined with alloplastic bone substitute soaked with rhBMP-2, and TJR could be well maintained for a long time. Moreover, intersegmental autogenous bone graft at the mandibular ascending ramus after SSRO enabled adequate frontal angulation of the mandibular part of the TJR with the improvement of mandibular asymmetry.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eTJR\u0026nbsp; \u0026nbsp;\u0026nbsp;Total joint replacement\u003c/p\u003e\n\u003cp\u003eHFM\u0026nbsp;\u0026nbsp;Hemifacial microsomia\u003c/p\u003e\n\u003cp\u003eTMJ\u0026nbsp; \u0026nbsp;Temporomandibular joint\u003c/p\u003e\n\u003cp\u003eFDA\u0026nbsp; \u0026nbsp;Food and Drug Administration\u003c/p\u003e\n\u003cp\u003eSSRO\u0026nbsp;\u0026nbsp;Sagittal split ramus osteotomy\u003c/p\u003e\n\u003cp\u003eDO \u0026nbsp; \u0026nbsp; Distraction osteogenesis\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eInformed consent was obtained from the patient for the publication of this case report.\u003c/p\u003e\n\u003ch2\u003eFunding\u003c/h2\u003e\n\u003cp\u003eNo funding was received.\u003c/p\u003e\n\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\n\u003cp\u003eKH Yu was responsible for data collection, investigation, visualization, and writing \u0026ndash; original draft. JJ Han contributed to resources and writing \u0026ndash; review. SJ Hwang was involved in methodology, project administration, supervision, validation, and writing \u0026ndash; review and editing.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eCascone P, Vellone V, Ramieri V, Basile E, Tarsitano A, et al. (2018) Reconstruction of the Adult Hemifacial Microsomia Patient with Temporomandibular Joint Total Joint Prosthesis and Orthognathic Surgery. Case Rep Surg 2018: 2968983.\u003c/li\u003e\n\u003cli\u003eBirgfeld C B, Heike C (2012) Craniofacial microsomia. Semin Plast Surg 26(2): 91-104.\u003c/li\u003e\n\u003cli\u003eL\u0026oacute;pez D F, Acosta D M, Rivera D A, Mej\u0026iacute;a C M (2022) Hemifacial microsomia: treatment alternatives-a systematic review of literature. J Clin Pediatr Dent 46(5): 15-30.\u003c/li\u003e\n\u003cli\u003eSubash P, V V P, Iyer S, Nerurkar S, Krishnadas A, et al. (2023) Concomitant Microvascular Aided Extended Temporo-Mandibular Joint Replacement (ME-TJR) and Stock Temporo-Mandibular Joint Replacement (MS-TJR) During Mandibular Reconstruction. J Maxillofac Oral Surg 22(Suppl 1): 110-117.\u003c/li\u003e\n\u003cli\u003eBriceno W X, Milkovich J, El-Rabbany M, Caminiti M F, Psutka D J (2022) Reconstruction of Large Defects Using Extended Temporomandibular Joint Patient-Matched Prostheses. J Oral Maxillofac Surg 80(6): 1018-1032.\u003c/li\u003e\n\u003cli\u003ePrada Madrid J R, Montealegre G, Gomez V (2010) A New Classification Based on the Kaban\u0026apos;s Modification for Surgical Management of Craniofacial Microsomia. Craniomaxillofac Trauma Reconstr 3(1): 1-7.\u003c/li\u003e\n\u003cli\u003eZanakis N S, Gavakos K, Faippea M, Karamanos A, Zotalis N (2009) Application of custom-made TMJ prosthesis in hemifacial microsomia. Int J Oral Maxillofac Surg 38(9): 988-992.\u003c/li\u003e\n\u003cli\u003eWolford L M, Perez D E (2015) Surgical management of congenital deformities with temporomandibular joint malformation. Oral Maxillofac Surg Clin North Am 27(1): 137-154.\u003c/li\u003e\n\u003cli\u003eTawfilis A R, Chappell E T, Farhood V W (2002) Alloplastic reconstruction of a temporal bone and glenoid fossa defect. J Oral Maxillofac Surg 60(9): 1079-1082.\u003c/li\u003e\n\u003cli\u003eChase D C, Hudson J W, Gerard D A, Russell R, Chambers K, et al. (1995) The Christensen prosthesis. A retrospective clinical study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 80(3): 273-278.\u003c/li\u003e\n\u003cli\u003ePolley J W, Girotto J A, Fahrenkopf M P, Dietze-Fiedler M L, Kelley J P, et al. (2019) Salvage or Solution: Alloplastic Reconstruction in Hemifacial Microsomia. Cleft Palate Craniofac J 56(7): 896-901.\u003c/li\u003e\n\u003cli\u003eHirota Y, Ueda K, Katayama M, Otsuki Y (2018) Functional Temporomandibular Joint Reconstruction in Costochondral Grafting of Micrognathia. Plast Reconstr Surg Glob Open 6(10): e1925.\u003c/li\u003e\n\u003cli\u003eRichter M, Dulguerov P, Pittet B, Becker M (1997) Immediate function of temporomandibular joint after total resection and reconstruction. J Craniofac Surg 8(5): 383-390.\u003c/li\u003e\n\u003cli\u003eMovahed R, Pinto L P, Morales-Ryan C, Allen W R, Wolford L M (2013) Application of cranial bone grafts for reconstruction of maxillofacial deformities. Proc (Bayl Univ Med Cent) 26(3): 252-255.\u003c/li\u003e\n\u003cli\u003eElledge R, Mercuri L G, Speculand B (2018) Extended total temporomandibular joint replacements: a classification system. Br J Oral Maxillofac Surg 56(7): 578-581.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"maxillofacial-plastic-and-reconstructive-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mprs","sideBox":"Learn more about [Maxillofacial Plastic and Reconstructive Surgery](http://jkamprs.springeropen.com/)","snPcode":"40902","submissionUrl":"https://submission.springernature.com/new-submission/40902/3","title":"Maxillofacial Plastic and Reconstructive Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Hemifacial microsomia, Zygomatic arch absence, Glenoid fossa reconstruction, Autologous bone graft, Stock total joint replacement, Frontal ramal angle","lastPublishedDoi":"10.21203/rs.3.rs-7056467/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7056467/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground\u003c/strong\u003e: In patients with hemifacial microsomia accompanied by mandibular fossa deficiency and severe atrophy of the mandibular ramus, customized total joint replacement (TJR) is commonly used to restore masticatory and joint function and improve facial asymmetry. However, in countries where customized TJR is not approved, or for patients for whom the cost is prohibitive, a stock TJR system must be considered. In cases with a severely medially inclined frontal ramal angle and a lack of supporting bone for the fossa component, using a stock TJR poses significant technical challenges.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCase presentation\u003c/strong\u003e: This case report describes the use of autogenous bone grafting to overcome these limitations. An 18-year-old male with HFM type IIB on the left side received staged procedures, including bone grafting between mandibular proximal and distal segments to increase the frontal ramal angle, autogenous reconstruction of the mandibular fossa to enable fixation of the TJR fossa component, and orthognathic surgery.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e: Successful functional and esthetic outcomes were achieved, with stable maintenance of a stock Biomet TJR over a seven-year period.\u003c/p\u003e","manuscriptTitle":"Total joint replacement with the stock Biomet system in adult hemifacial microsomia without glenoid fossa: A case report and literature review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-15 09:49:20","doi":"10.21203/rs.3.rs-7056467/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-07-24T22:49:52+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-24T19:14:54+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-23T16:05:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"307732315209341419053155340284188886631","date":"2025-07-21T13:42:39+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-20T14:55:06+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"87845023488379565461025515485067379154","date":"2025-07-20T14:39:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-17T18:30:54+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30962425731521941017451578932275439275","date":"2025-07-16T13:41:49+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-16T11:18:29+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"35427207497310615939290311893711203957","date":"2025-07-12T02:26:32+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"69721183811490362102463301929084233922","date":"2025-07-12T01:02:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"169362025948786418248658633624988881033","date":"2025-07-10T04:48:45+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-09T22:28:45+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-07-09T02:01:51+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-09T02:00:09+00:00","index":"","fulltext":""},{"type":"submitted","content":"Maxillofacial Plastic and Reconstructive Surgery","date":"2025-07-06T07:41:46+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"maxillofacial-plastic-and-reconstructive-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"mprs","sideBox":"Learn more about [Maxillofacial Plastic and Reconstructive Surgery](http://jkamprs.springeropen.com/)","snPcode":"40902","submissionUrl":"https://submission.springernature.com/new-submission/40902/3","title":"Maxillofacial Plastic and Reconstructive Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Open","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"92f9d278-79cd-4ea5-83d0-2f97c81a5032","owner":[],"postedDate":"July 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2025-10-20T16:07:19+00:00","versionOfRecord":{"articleIdentity":"rs-7056467","link":"https://doi.org/10.1186/s40902-025-00478-5","journal":{"identity":"maxillofacial-plastic-and-reconstructive-surgery","isVorOnly":false,"title":"Maxillofacial Plastic and Reconstructive Surgery"},"publishedOn":"2025-10-15 15:57:15","publishedOnDateReadable":"October 15th, 2025"},"versionCreatedAt":"2025-07-15 09:49:20","video":"","vorDoi":"10.1186/s40902-025-00478-5","vorDoiUrl":"https://doi.org/10.1186/s40902-025-00478-5","workflowStages":[]},"version":"v1","identity":"rs-7056467","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7056467","identity":"rs-7056467","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}