PMC9836793_01
Front view showing facial asymmetry with mandibular deviation towards the left side.
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Extraoral examination showed minimal facial asymmetry with slight mandibular deviation on opening towards the left side, no mandibular retrognathism, and hardly noticeable elongation of the face on the unaffected side (Figure 1).
A pre-operative orthopantomography (OPG) of the patient.
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A narrowed TMJ space and evidence of left TMJ ankylosis was detected (Figure 2), which was subsequently confirmed by coronal views and a 3-D reformatted computed tomography scans (Figures 3 and 4).
A 3-D reformatted CT scan of the patient showing left TMJ ankylosis and elongated left coronoid process.
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A narrowed TMJ space and evidence of left TMJ ankylosis was detected (Figure 2), which was subsequently confirmed by coronal views and a 3-D reformatted computed tomography scans (Figures 3 and 4).
A coronal CT scan view showing left TMJ ankylosis.
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A narrowed TMJ space and evidence of left TMJ ankylosis was detected (Figure 2), which was subsequently confirmed by coronal views and a 3-D reformatted computed tomography scans (Figures 3 and 4).
Endaural approach to access the ankylotic mass.
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TMJ was approached using endaural approach (Figure 5).
An intra-operative view of the ankylotic mass.
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A subperiosteal plane of dissection was performed until the hard sclerotic mass was visible (Figure 6).
Osteotomy of the ankylotic mass.
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An osteotomy inferior to the ankylotic mass was done using a Lindemann bur while the tissues and vasculature medial to the ramus were protected using anterior and posterior Dunn-Dautrey retractors (Figure 7).
A gap is created following the removal of the ankylotic mass.
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Inter-incisal opening following removal of the ankylotic mass.
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The TMJ was then manipulated, and an inter-incisal distance of approximately 35 mm (the width of the surgeon's 3 fingers) was achieved (Figure 9).
Harvesting the costochondral graft.
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Subsequently, a straight incision over the fifth rib was carried out, and around 8 mm length of the right fifth rib along with attached chondral part was harvested (Figure 10).
The graft is secured to the lateral side of the ramus.
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The graft was fixed with 3 bicortical screws in a line to the lateral side of the ramus without complete tightening of the middle screw to protect the curved from fracture from excessive force of the screw on the middle of its harvested length (Figure 11).
A post-operative 3-D reformatted image of a CT scan showing the graft in place.
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A CT scan taken 2 weeks post-operatively revealed that graft was stable in place (Figure 12).