The “green-stick” fracture technique for adaptation and fixation of costochondral grafts

Abstract

Since firstly reported in 1920 by Gillies,’ costochondral grafts have been used by the oral and maxillofacial surgeon to replace a damaged mandibular condyle and reconstruct the temporomandibular joint CIMS). Nowadays, it has found application of the in cases of congenital dysplasia and developmental defects, ankylosis of the TMJ, neoplastic disease, osteoarthritis, and posttraumatic dysfunction2* Initially, the grafts were fixed to the mandibular ramus with wires, with the disadvantages of cutting through graft cuts and fractures because of the thin rib cortex.* Later, rigid fixation with titanium screws or miniplates was the rule and today is probably the method of choice.5 However, sometimes in young patients the weakness of the rib graft cortex results in intrusion of the screw head into the graft and movement or fracture of the graft when placing isolated bicortical lag screws6 This may be obviated by positioning the lag screw through the holes of a titanium miniplate. Other variations in the method of the fixation have been reported throughout the years.2-8 Another problem encountered with rib grafts is that the graft and the rib and the ascending romus of the mandible have opposite curvatures, and during surgery a space can occur between the mandible and the graft. This fact can lead to unexpected complications, such as delayed or incomplete ossification in the recipient site, thereby leading to a lack of stability and increasing the risk of pseudarthrosis. In 1989, Mosby and Hiatt9 described a new technique to securely fix the graft and therefore diminish the gap between the rib and mandible, while pressing the rib graft against the mandibular surface. We have developed a varia