###### Abstract  
Extended postoperative mandibular reconstructions due to orofacial disease involving the temporomandibular joint (TMJ) in immature patients remain a challenge as a result of ongoing growth, which is usually affected by the disease and treatment. Current reconstructive techniques based fully on alloplastic total joint replacement fail to meet fully the anatomical and functional requirements for the masticatory system and speech development. Fourteen children aged 12.6 \(\pm\) 2.6 with tumors or congenital deformities affecting the mandible and TMJ were included in the study. Radical surgical treatment according to our own protocol was performed through microvascular anastomotic flap reconstruction of the soft tissues and bones, together with total TMJ custom replacements. Follow-up lasted 2-6 years. During the follow-up, increases in the mandible body (13% growth) and rams (12% growth) were observed, both of which were related (_p_ < 0.001). This is the first report concerning the immediate reconstruction of the mandible with rams and total TMJ in children and adolescents that combines a free vascularized graft and total individual prosthesis of the TMJ. The presented technique enabled optimal function of the TMJ, growth of the mandible, and further rehabilitation of the patients. The technique was demonstrated to be safe, reliable, and provide good functional and cosmetic outcomes. m xxxillofacial; pediatric; surgery; cancer; reconstruction; microsurgery; TMJ; custom implants +
Footnote †: journal: Medical  
* Attachment of the resected condyle as a nonvascularized transplant to the end of the bone free flap;
* Insertion of a condylar prosthesis in addition to the vascularized bone graft into the glenoid fossa or the use a free bone graft alone, such as a fibula free flap, second metatarsophalangeal joint free flap, vascularized scapular, or clavicle flap;
* Use of nonvascularized tissues, such as a costochondral rib flap with a deep circumflex iliac artery flap. At present, the use of alloplastic total joint replacement (TMJR) (with or without bone grafting) is widely accepted and has presented satisfactory long-term outcomes. While TMJR is the scientifically proven treatment of choice in adults, the optimal protocol for TMJ reconstruction in immature patients remains unclear. The resection of part of the mandible with its condyle and the need for reconstruction of its lost elements in children frequently have different pathological backgrounds and desired treatment needs. In children and adolescents, the TMJ loses its physiological function mostly due to malignancies, congenital deformities, and ankyloses [2]. As a consequence this results in the disturbance of orofacial development, asymmetry, malocclusion, breathing, and food intake problems, which require long-term multidisciplinary dental treatment, rehabilitation, physiotherapy, and psychological support since the disease frequently results in social distancing, depression, and mental health problems [3]. Therefore, there is an undisputable need to develop reliable techniques that enable functional reconstruction of the TMJ in children and adolescents while allowing for subsequent physiological growth of the orofacial skeleton, a reduction in posteroperational complications and a reduction in the need for future secondary surgeries. The first reports describing the sole use of alloplastic devices in immature patients were published by [PERSON] et al. [4], [PERSON] et al. [5], and [PERSON] et al. [6]. While these described satisfactory results, they indicated the need for further studies in this area. Additionally, data from the clinical studies have implied the justified use of microvascular bone grafting techniques in the reconstruction of the resected mandible in children [7; 8; 9]. Virtual surgical planning (VSP) and custom surgery protocols have found reliable application in contemporary dentistry and oral surgery when plastic, metal, or ceramic materials are used [10; 11].