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GROWTH CENTER TRANSPLANTATION USING COSTOCHONDRAL RIB GRAFT FOR BILATERAL TMJ ANKYLOSIS CORRECTION

19/5/2016

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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.
Preoperative profile view showing retruded mandible with ill defined chin at the age of 6
Preoperative OPG showing reduced right joint space.
Intraoperative view of the ankylotic mass
Post gap arthroplasty
Preop view at the age of 15 showing severe retrognathic mandible with restricted mouth opening. Note the double chin deformity
Mouth opening with chin deviation and double chin deformity
Profile view showing retruded chin with deficient hyo-mental distance
Preoperative 3DCT view showing hypertrophic coronoid process
Preoperative 3D CT lateral view showing obliterated joint space with hypertrophic coronoid process
Harvesting of the rib graft-following a curvilinear incision layerwise dissection done exposing the right sixth rib
Harvested rib graft with the cartilage cap
Securing of the cartilagenous graft using 4-0 Prolene
Graft introduced into the surgical site for TMJ reconstruction
Securing of the graft at the mandibular posterior border using stainless steel L plates
Postoperative view at the age of 20
Postoperative mouth opening with no chin deviation
Postoperative profile view showing enhanced appearance with prominent chin and increased hyo-mental distance
Pre and postoperative profile view. Note the improvement in facial profile.
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