**5.2 Unilateral TMJ reconstruction, split sagittal osteotomy on the contralateral side, with possible subsequent maxillary surgery**


Note 1: For mandibular advancement or CCW rotation of the mandible, it is advisable to thoroughly relax the masticatory muscles. TJR surgery usually involves stripping the masseter muscle and detaching the lateral pterygoid muscle through condylectomy. In the case of coronoidectomy, the ligament of the temporal muscle is detached. In case of more extensive mandibular repositioning, the authors recommend detaching the pterygomasseteric sling at the edge of the mandible and stripping the lower part of the medial pterygoid muscle from the inner surface of the mandibular ramus (within 1 cm above the edge of the mandible).

Note 2: There is a different algorithm for performing orthognathic surgery with TJR in patients with ankylosis. Unless performing surgery only or surgery first, then patients with ankylosis will first undergo an ankylosis resection. This allows the mobilization of the jaw and at the same time allows the start of orthodontic preparation. Only after this is completed is orthognathic surgery performed, together with TJR. Spacers are inserted into the resected ankylosis site (most often bone cement) to prevent reankylosis.

### **6. Postoperative regimen and care, follow-up system**

The postoperative regimen fundamentally differs depending on the scope of the surgery.

If mandibular repositioning is performed using bilateral TJR without maxillary surgery, then the postoperative regimen consists of [13, 16]:


In patients where TJR is performed concurrently with SSO or maxillary surgery, the postoperative regimen consists of [13, 16]:


Patients at the authors' workplace are typically hospitalized for several days after the surgery. In case of orthognathic surgery with TJR of the TMJ, hospitalization time is 3–7 days.

After surgery, each patient is scheduled for regular follow-up examinations at the authors' workplace at 2 weeks, one month, three months, 6 and 12 months after the procedure, and then regularly once a year after that [13].

Note 1: The authors prefer individual rehabilitation that largely relies on the patient's cooperation. The patient is instructed in methods for the rehabilitation of mouth opening and gentle muscle massages. If this rehabilitation is insufficient, a specialist, a physiotherapist, is brought in to help. The authors recommend specialized physiotherapy in case of complications – e.g., involvement of the facial nerve, trigeminal nerve [13].

Note 2: The risk of anterior dislocation of the prosthesis is increased due to the detachment of the ligaments of the masticatory muscles from the mandible (especially if a coronoidectomy was performed at the same time). It is appropriate to test the maximum range of motion of the mandible at the end of the surgery and to record whether or not dislocation occurs during maximal abduction [17]. If there is a risk of dislocation, temporary intermaxillary fixation with elastic bands is maintained (usually for the first postoperative week) [15].
