A 5 year old boy was brought to our hospital with a complaint of decreased mouth opening and facial deformity by birth. His parent’s gave the history of multiple surgical correction of TMJ ankylosis done elsewhere. He had unsightly extraoral scar due to previous surgeries. He gave a history of having undergone distraction osteogenesis treatment for the left side of the lower jaw in some other hospital elsewhere, but the treatment subsequently failed.

Now on examination he had facial asymmetry, severely retruded lower jaw (mandible), flattened lower face with complete restriction in mouth opening and shift of chin towards left side.
3DCT of facial bones revealed obliterated left temporomandibular (joint jaw) joint space, elongated coronoid process, and reduced ramal height and prominent antegonial notch. The case was diagnosed as true left TMJ bony ankylosis with developing secondary facial deformity. 
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Maxillofacial Surgeon Dr. S. M. Balaji successfully performed bony ankylosis release surgery and transportation of growth centre using costochondral junction obtained from rib cartilage. Postoperative mouth opening was adequate. Following complete dental rehabilitation done to treat the badly broken and decayed teeth, boy’s parents were asked to continue the mouth opening exercise at least 2 months after surgery. 

A 6 year old boy was brought to our hospital with a complaint of decreased mouth opening and facial deformity. No history of trauma elicited by his parents. Extra oral examination revealed severely retruded mandible, flattened lower face and complete restriction in mouth opening.
OPG revealed obliterated right joint space elongated coronoid process, reduced ramal height and prominent antegonial notch. The case was diagnosed as true right TMJ bony ankylosis with developing secondary facial deformity.  
Maxillofacial Surgeon Dr. S. M. Balaji successfully performed gap arthroplasty using temporalis flap interpositioning. Followed by active physiotherapy, mouth opening improved dramatically. But patient failed to be on regular follow up.
After 9 years, exactly at the age of 15, patient reported with the complaint of restricted mouth opening, severe secondary facial deformity and retruded chin giving bird face appearance.
On thorough clinical and radiological examination, it was diagnosed as left TMJ ankylosis with functional right pseudo joint. Dr. S. M. Balaji performed left gap arthroplasty and bilateral condylar component reconstruction using 5th and 7th costochondral rib graft (CCG).
Postoperative mouth opening was adequate. Over 8 years follow up, bilateral CCG was favorable and lower facial projection was improved significantly with increased mouth opening.

22 year old female, a known case of bilateral TMJ ankylosis reported to our hospital for the surgical correction of lower half of the face. Micrognathic mandible present due to retarded development. She gave the history of TMJ ankylosis release surgery done elsewhere during childhood.
After thorough clinical and radiological examination Maxillofacial Surgeon Dr. S. M. Balaji planned to correct the facial asymmetry using internal distraction osteogenesis with maxillomandibular distractor. Bilaterally Paragingival incision was placed over the angle region along the anterior border of ramus. Full thickness mucoperiostal flap was reflected buccally and bone exposed. The direction of the osteotomy cut and positioning of the distractor is the most important as it determines the vector of distraction and this determines the direction of the bone growth. The distractor device was positioned and fixed using screws. Osteotomy is then completed along the medial cortex. Distractor device was checked and wound closure done. Le Fort I osteotomy was completed in maxilla.
After a latency period of 5 days, distraction at the rate of 1 mm per day was accomplished and facial asymmetry was successfully corrected. Thus maxillomandibular distraction technique helped dramatically to enhance the facial appearance without any visible scars and taking autobone graft anywhere from the body. Patient feels very happy to have enhanced facial appearance without any scar on the face.