Anesthetic Implications of Previously Undiagnosed Temporomandibular Joint Ankylosis: A Case Report.

Temporomandibular joint (TMJ) ankylosis is characterized by bony fusion that limits TMJ mobility. We present the case of an elderly woman who was brought to the operating room for dental rehabilitation under general anesthesia. The patient had an undiagnosed TMJ ankylosis, which was discovered only after induction of anesthesia due to her nonverbal status and advanced dementia. The surgical team canceled the case due to limited access to the surgical field. We discuss the factors that suggest TMJ ankylosis and propose the perioperative management when TMJ ankylosis is suspected but unconfirmed.

Pediatric temporomandibular joint ankylosis and arthritis: Forgotten complications of acute otitis media.

OBJECTIVES: Temporomandibular joint (TMJ) arthritis and ankylosis represent unusual but potential complications of ear suppuration, especially in children. We performed a review of the literature of pediatric otogenic TMJ arthritis and ankylosis, discussing their clinical and radiological features, their mechanism of infection spread, and the importance of a prompt diagnosis and treatment. We additionally describe a case of TMJ ankylosis following acute mastoiditis in a 4-year-old female patient. METHODS: A search of English literature from January 1, 1980 to December 31, 2021 was performed on the electronic databases (PubMed, Web of Science and Scopus) in order to identify studies concerning TMJ complication after ear suppuration. RESULTS: Seventeen articles were considered eligible for the review. Eight and nine studies described otogenic TMJ ankylosis and arthritis, respectively. A total of 17 children affected by ankylosis consequent to ear infection and a total of 31 cases of TMJ arthritis concurrent to otomastoiditis were identified. Mean time elapsed between ear infection and diagnosis of TMJ ankylosis was 4.8 years (range 0.5-13). CONCLUSION: TMJ involvement during complicated otitis media should be kept in mind. Its prompt recognition is mandatory to set up appropriate treatment and follow-up and reduce the risk of ankylosis with its functional and psychological complications.

Does Evoked Electromyography Detect the Injured Facial Nerve Recovery Earlier Than Clinical Assessments?

PURPOSE: The key element in managing postoperative facial nerve (FN) injuries is timely diagnosis and intervention as indicated. The purpose of this study was to measure and compare evoked electromyography (EEMG) and clinical assessment in terms of the recovery of the injured FN in operated temporomandibular joint ankylosis (TMJA) cases. METHODS: The investigators designed a prospective cohort study in the primary operated TMJA patients. The primary predictor variable was the technique used to assess FN function, House-Brackmann Facial Nerve Grading System (HBFNGS) or EEMG. The primary outcome variable was time to FN recovery. The FN recovery was assessed in different time points (1 week, 1 month, 3 months, and 6 months). Age, gender, side (unilateral/bilateral), type of ankylosis (Sawhney's classification), and operating time were kept as covariates. Categorical variables were analyzed using Fisher's exact test. Multilevel survival analysis was performed considering the subject as cluster to perform Kaplan-Meier analysis and compute the hazards ratio using the Cox-regression method with adjustment for covariates. P <0.05 was set as statistically significant. RESULTS: The study sample composed of 43 (69 sides) TMJA cases who underwent surgery developed iatrogenic FN injury in 10 cases (14 sides [9 right; 5 left]). The incidence of FN injury was 20.3% (14/69). Sawhey's type III/type IV ankylosis and the operating time for more than 2 hours showed a statistically significant (p<0.05) increase in FN injury. The mean duration to detect FN recovery by EEMG was 9 days (95% confidence interval, 5 to 12 days), but the HBFNGS took 161 days (95% confidence interval, 141 to 181 days). The chance of early detection by EEMG was 18.6 times more than the chance by the HBFNGS (Cox-hazard ratio, 18.6). CONCLUSIONS: To conclude, EEMG is a noninvasive and reliable tool that detects FN recovery much earlier than the HBFNGS in the postoperative TMJA cases.

Multicenter Study of Congenital Middle Ear Anomalies. Report on 246 Ears.

OBJECTIVES/HYPOTHESIS: Congenital middle ear anomalies represent a relatively rare condition. This study aimed to describe the characteristics and the surgical outcomes for patients with middle ear anomalies. METHODS: A multicenter study was conducted of consecutive patients with congenital middle ear anomalies who underwent primary surgical treatment between January 2008 and December 2017. Demographics, surgical procedures, and audiometric data were registered into the institutional database. Hearing changes and postoperative air-bone gap (ABG) were evaluated 1 year after surgery. RESULTS: A total of 246 patients (246 ears) (median age: 14 years, range: 4-75 years old) were included in this study. Anomalies were subdivided using the Teunissen and Cremers classification: 53 ears (22%) were categorized as class I, comprising only stapes ankylosis; 35 ears (14%) as class II, having ossicular chain anomalies with stapes ankylosis; 139 ears (57%) as class III, having ossicular chain anomalies with a mobile stapes-footplate; and 19 ears (8%) as class IV, with aplasia of the oval window. Evaluation of hearing outcomes for 198 ears with more than 1 year of follow-up revealed that good postoperative ABG (≤20 dB) was achieved in 82% of class I, 68% of class II, 74% of class III, and 23% of class IV anomalies. The postoperative ABG in class IV was significantly worse than in class I (P < .001) or class III (P < .01). CONCLUSIONS: This study demonstrated that class III anomalies comprised the majority of middle ear anomalies and surgical outcomes for class IV anomalies are unfavorable. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:E2323-E2328, 2021.

Longitudinal electromyographic changes in masseter and anterior temporalis muscle before and after temporomandibular joint arthroplasty in ankylosis patients.

PURPOSE: The literature lacks evidence about activity of masseter and anterior temporalis muscles in temporomandibular joint ankylosis (TMJA) patients. The purpose of this study was to evaluate longitudinal electromyography (EMG) changes in masseter and anterior temporalis muscle before and after gap arthroplasty in unilateral TMJA patients. Specific aim was to investigate the EMG activity restoration to the level of non-ankylosed side after arthroplasty. METHODS: The investigator implemented a prospective longitudinal study amongst TMJA patients treated with gap arthroplasty. EMG of masseter and anterior temporalis were recorded bilaterally on ankylosed and non-ankylosed side. EMG signals of masseter and anterior temporalis were recorded preoperatively and 1 week, 3 month and 6 month postoperatively at rest and at maximum voluntary clench (MVC). RESULTS: The study sample was composed of 16 (male:female = 1:1.28) unilateral TMJA patients. The mean duration of ankylosis was 3.25 ± 1.18 years. The difference in EMG root-mean-square (RMS) values of ankylosed side when compared to the preoperative values of non-ankylosed side was found to be statistically significant (p < 0.001) preoperatively, 1 week and 3 month postoperatively, while it was statistically not significant (p > 0.99) at 6-month postoperatively. CONCLUSION: The present study concludes that the TMJA patients have hyperactivity of masseter and anterior temporalis muscle. Restoring the function causes the muscle activity to progress to the values of normal side. EMG activity as measured on follow-up may be one of the predicting factor for re-ankylosis.

Temporomandibular joint alloplastic reconstruction of post-traumatic joint degeneration with Sawhney Type I ankylosis using 3D-custom GD-condylar cap prosthesis to restore condylar form and function.

Temporomandibular Joint (TMJ) ankylosis as a sequelae following hemarthrosis from trauma, middle ear infection and progressive debilitating arthritis of various etiologies has been well understood, but challenges always arise in terms of choosing least morbid procedure with maximum functional outcome. Total joint replacement (TJR) is the common final stage correction mandating extensive surgical exposure with good technical expertise with its limitations of risk of failure and complications. A case of post-traumatic TMJ degeneration with ankylosis reconstructed using a customised GD-condylar cap prosthesis is described. The patient had an uneventful post-operative period with an acceptable functional outcome. CONCLUSION: The condylar cap prosthesis is a bio-compatible and biomechanically designed in such a way that it can be used for indicated cases by performing minimally invasive surgical technique to achieve an optimal functional and aesthetic outcome.

Surgical strategies in management of ankylosed bilateral hips and knees in crouched posture.

A 26-year-old wheelchair-bound man was brought to our institute with progressive painful deformity of both lower limbs involving bilateral hip and knee for the past 5 years. The patient was wheelchair-bound for the past 18 months. He was only able to crawl to meet his locomotor demands. On examination, the patient was in a crouched posture with mild kyphosis at the thoracolumbar region and ankylosis of bilateral hip and knee in an unfavourable position. Radiological and serological evaluation diagnosed him to be a case of neglected ankylosing spondylosis. We planned for arthroplasty of the bilateral hip and knee for correcting his posture and to regain his locomotor ability. The severity of the deformity mandated extensive releases and the handling of neurovascular structures. Hence, a holistic treatment plan with various surgical strategies was devised to manage his deformities. The patient made a good recovery and regained his locomotor ability without any major complications at a 2-year follow-up.

Prosthetic temporomandibular joint reconstruction in a cohort of adolescent females with juvenile idiopathic arthritis.

BACKGROUND: Temporomandibular joint (TMJ) arthritis and involvement is commonly seen in Juvenile Idiopathic Arthritis (JIA). Therapy includes conservative measures, but also includes intraarticular corticosteroid injections (IASI) and systemic immunosuppressive therapy. Despite aggressive medical therapy, some patients develop arthritic changes and frank TMJ ankylosis that can result in persistent pain and limitation in range of motion (ROM). A surgical option is prosthetic TMJ replacement with concurrent correction of dentofacial deformities, which can be performed simultaneously. The objective of this study was to evaluate the outcomes of prosthetic TMJ replacement in a cohort of adolescent females with JIA and severe TMJ involvement. METHODS: This is a retrospective case series that took place at one tertiary care center. Patients with a diagnosis of JIA who also underwent alloplastic TMJ replacement were identified through electronic medical record system (EMR) and reviewed. Chart review included analysis of all documents in the EMR, including demographic data, JIA history, surgical complications, ROM of TMJ measured by maximal incisal opening in millimeters (mm) and TMJ pain scores (4-point Likert scale: none, mild, moderate, severe) obtained pre- and postoperatively. RESULTS: Five female patients, ages 15-17 year when TMJ replacement was performed, had nine total joints replaced with a post-operative follow-up period of 12-30 months. All patients had polyarticular, seronegative JIA and were treated with IASI and multiple immunosuppressive therapies without resolution of TMJ symptoms. One patient had bilateral TMJ ankylosis. Three of the five patients demonstrated significant dentofacial deformities, and all underwent simultaneous or staged orthognathic surgery. All patients had improvement in TMJ pain with most (80%) reporting no pain, and all had similar or improved ROM of their TMJ postoperatively. There was one delayed postoperative infection with Cutibacterium Acnes that presented 15 months after surgery and required removal and reimplantation of prosthesis. CONCLUSION: The sequelae of TMJ arthritis and involvement from JIA in the adolescent population can be difficult to treat. Current medical therapy can be successful, however, in select cases that develop chronic changes in the TMJ despite extensive medical therapy, early results show that prosthetic joint replacement maybe a reasonable surgical option. With prosthetic joint replacement pain levels were reduced and range of motion was maintained or improved for all patients.

Coronoidoplasty in TMJ ankylosis treatment.

A 2-year-old boy was brought by his parents with complaints of difficulty in mouth opening for the past one and half years. He had difficulty in chewing and was malnourished, with developing facial asymmetry. He was diagnosed with right side temporomandibular joint ankylosis. We planned for surgical removal of the ankylotic mass. But we modified the treatment protocol. Instead of doing coronoidectomy after aggressive excision of the ankylotic mass as advocated by Kaban, we did a 'coronoidoplasty' after aggressive excision of the ankylotic mass. Coronoidotomy or coronoidectomy is one of the rungs in the treatment ladder that is followed in surgical management of temporomandibular joint ankylosis. But one of the postoperative complications after coronoidectomy is the open bite. The difficulty to close the mouth becomes more pronounced when bilateral coronoidectomy is done. However, 'coronoidoplasty', as we have done for this patient retains the action of the temporalis muscle on the mandible in closing the mouth, yet removes the mechanical interference of the coronoid process. Postoperatively the patient was able to clench his teeth well, chew properly and there was no open bite.

Total hip arthroplasty by direct anterior approach in the lateral position for the treatment of ankylosed hips.

OBJECTIVE: To investigate the clinical efficacy of total hip arthroplasty (THA) via the direct anterior approach (DAA) for the treatment of hip ankylosis in the lateral position. METHODS: A retrospective analysis was performed on the clinical data of 24 patients (39 hips) who underwent THA via the DAA in the lateral position for the treatment of hip ankylosis between January 2016 and December 2018. We performed bilateral THA for fifteen patients and unilateral THA for nine patients. Operation time, intraoperative blood loss, length of incisions, straight leg-raising time, length of postoperative hospital stay, operation-related complication, prosthesis position, radiological outcomes, postoperative pain relief (evaluated by VAS) and functional rehabilitation [evaluated by Harris hip score and range of motion (ROM)] were analyzed to determine clinical efficacy. These clinical data were compared and statistically analyzed with the clinical data of another 23 patients (28 hips) who underwent THA via the posterolateral approach (PLA) for the treatment of hip ankylosis in the lateral position. RESULTS: Follow-up was performed at 12-15 months. The incision length in the DAA group and the PLA group was (11.12 ± 1.69 vs. 14.36 ± 3.42) cm, the intraoperative blood loss was (371.25 ± 120.55 vs. 396.80 ± 101.21) ml, the operation time was (122.47 ± 25.40 vs. 138.47 ± 24.45) min, the postoperative hospital stay was (9.59 ± 4.62 vs. 12.08 ± 3.58) days, and the straight leg elevation time was (9.20 ± 2.12 vs. 12.34 ± 3.25) days, respectively. The prosthesis of the two groups was in a good position: The average angle of cup anteversion in the DAA group and the PLA group was (10.76 ± 2.84 vs. 15.36 ± 3.42)°, and the average angle of cup abduction in the DAA group and the PLA group was (40.00 ± 3.45 vs. 41.21 ± 2.85)° (P > 0.05). The VAS score, ROM and Harris score at different follow-up time points were significantly improved in the two groups compared with those before surgery. In the first 3 months after surgery, the VAS score, ROM and Harris score of the DAA group were significantly better than those of the PLA group (P < 0.05), but with the extension of the follow-up time, there was no significant difference in the above indicators between the two groups (P > 0.05). One case of greater trochanteric fracture occurred in the DAA group. Two cases of hip posterior dislocations occurred in the PLA group, and no dislocations occurred after manual closed reduction and hip fixation in bed for 1 month to the last follow-up. No complications such as infection, deep vein thrombosis, fat embolism, prosthesis loosening, limb length inequality or joint dislocation were reported. CONCLUSION: THA via the DAA for the treatment of hip ankylosis in the lateral position was safe and effective and had the advantage of reduced trauma, quicker recovery of hip function, lower incidence of postoperative dislocation and ability to expose the acetabulum fully and fit the prosthesis properly, providing satisfactory clinical efficacy.

Long-term results of cementless total hip arthroplasty for the treatment of ankylosed hip.

PURPOSE: The purpose of this study was to report the long-term results of total hip arthroplasty (THA) for the treatment of ankylosed hip. METHODS: Twenty-nine consecutive THAs were performed in 26 patients. The mean age of the patients at the time of the operation was 43.3 years (range, 19-69 years). We used cementless fixation in all hips and the mean duration of follow-up was 10.1 years (range, 4.5-20 years). Radiological evaluation of components, osteolysis, radiolucent lines and loosening were assessed. The Harris Hip Score (HHS), range of motion (ROM), limb-length discrepancy and walking capacity with or without any support were used preoperatively and at final follow-up for clinical evaluation. Survivorship analysis was conducted using the Kaplan-Meier method using second revision for any reason as the endpoint. RESULTS: The mean HHS was 85.6 (range, 55-98) points and mean ROM was 110.5° for flexion. The mean limb-length discrepancy improved from 4.1 cm to 1.1 cm. Positive Trendelenburg sign was recorded in 31% of the patients and 24% of patients needed any support for walking postoperatively. We observed surgical complications related to abductor arm in 25% of the patients. Radiolucency on the acetabular side was seen on one or more zones in 15 patients (16 hips). One aseptic acetabular component loosening was observed. On the femoral side, 11 patients demonstrated non-progressive radiolucent lines and osteolysis around the stem was seen in four hips but there was no aseptic stem loosening. The Kaplan-Meier survival rate considering revision for any reason as the endpoint was 81.5%, for aseptic loosening 91.3%, for a worst-case scenario of 66.4% at 10 years. CONCLUSION: Cementless fixation showed good to excellent results at 10 years. Preoperative and postoperative abductor status of the patient is critical for patient satisfaction.

[Arthrotic ankylosis of the temporomandibular joint]. / Ankylose de l'articulation temporo-mandibulaire post-arthrosique.

Ankylosis of the temporomandibular joint (TMJ) is a joint stiffness with an oral aperture of less than 30 mm measured between the incisors, occurring because of a bony, fibrous or fibro-osseous fusion. Arthrosis is a rare cause of the ankylosis of the temporomandibular joint. We report a case of ankylosis of the TMJ due to osteoarthrosis, in order to highlight the diagnostic and therapeutic features of this quite uncommon disease.

Pseudoankylosis Between Lateral Pterygoid Plates and Mandible: Report of One Case.

Temporomandibular joint (TMJ) ankylosis is the abnormal fusion of TMJ anatomic components that impedes free jaw movements. This restriction in motion ranges from minimal to a complete inability to open the jaw. This condition can be categorized as true ankylosis, which is attributed to pathologic conditions of the TMJ, or false ankylosis (pseudoankylosis), which describes restrictions of movement resulting from extracapsular abnormalities outside the TMJ. The literature shows that trauma is the leading cause of TMJ disorders and appears to be the most common cause of pseudoankylosis. Pseudoankylosis caused by pterygomandibular bony impingement has rarely been reported in the literature. This case report adds a new case of pseudoankylosis to the existing scanty literature, which was characterized by bilateral mechanical impingement between abnormally elongated lateral pterygoid plates and the coronoid processes of the mandible.

Ankylosis of the Coronoid Process to the Zygomatic Bone: A Case Report and Review of the Literature.

PURPOSE: Extra-articular temporomandibular bony ankylosis between the zygomatic bone and coronoid process is a rare condition. Currently, there are fewer than 40 cases reported in the English-language literature. The aim of this study was to report a case of zygomatico-coronoid ankylosis with surgical intervention and a literature review. MATERIALS AND METHODS: Through a PubMed search from 1946 to February 2018, using the terms ("extra-capsular" OR "zygomatico-coronoid" OR "extra-articular") AND ("ankylosis"), 61 articles were initially identified. After screening, manual reviewing, and including additional articles through reviews of the reference lists, 26 reports (33 patients) were included in the analysis. RESULTS: Patients' age ranged from 12 to 71 years (mean, 36.62 yr; standard deviation, 16.24 yr). The gender composition of patients was male (n = 20; 60.6%), female (n = 12; 36.4%), and unknown (n = 1; 0.3%), with a clear male predominance. The etiologies were trauma (n = 25; 75.8%), infection (n = 3; 9.1%), surgical complication (n = 4; 12.1%), and radiotherapy for maxillary cancer (squamous cell carcinoma; n = 1; 3.0%). The treatment options were surgical intervention through an intraoral approach (n = 19; 57.6%), an extraoral approach (n = 10; 30.3%), and intraoral and extraoral approaches (n = 2; 6.1%) and nonsurgical intervention (n = 2; 6.1%). CONCLUSION: Zygomatico-coronoid ankylosis is a possible cause of mouth-opening limitation, particularly in relation to facial trauma. However, it can be easily overlooked because of the rarity of zygomatico-coronoid ankylosis and the attention focused on the joint. Surgical intervention is regarded as a good treatment to improve mouth-opening limitation.

Endoscopically Assisted Transoral Gap Arthroplasty of the Temporomandibular Joint Ankylosis in a Pediatric Patient.

Surgical management of temporomandibular joint (TMJ) ankylosis in children is often challenging and may result in various complications such as facial nerve injury and visible scar. In this clinical report, the authors present minimally invasive management of a 9-year-old boy with bilateral post-traumatic TMJ ankylosis. The ankylotic TMJs were addressed and gap arthoplasties were performed by endoscopically assisted transoral approach. The risk of facial nerve injury is minimized and facial scar was prevented by avoiding extraoral incision. Mandibular movements in 3 directions were satisfactory at 3rd postoperative month.

Turning the backbone into an ankylosed concrete-like structure: Case report.

RATIONALE: Progressive restriction of the spinal bio-mechanics is not-uncommon deformity encountered in spine clinics. Congenital spinal fusion as seen in Klippel-Feil-anomaly, progressive non-infectious anterior vertebral fusion, and progressive spinal hyperostosis secondary to ossification of the anterior longitudinal spinal ligament are well delineated and recognized. PATIENT CONCERNS: A 24-year-old girl has history of osteoporosis since her early childhood, associated with multiple axial and appendicular fractures and scoliosis. Recently she presented with episodes of severe back pain, spinal rigidity/stiffness with total loss of spine biomechanics. DIAGNOSES: She was provisionally diagnosed as having osteogenesis imperfecta and was investigated for COL1A1/A2 mutations which have been proven to be negative. Autosomal recessive type of osteogenesis imperfecta was proposed as well, no mutations have been encountered. A homozygous for CTSA gene mutation, the gene associated with Galactosialidosis was identified via whole exome sequencing (Next-Generation Sequencing projects) has been identified. INTERVENTIONS: Early in her life she had a history of frequent fractures of the long bones since she was 4 years which was followed by vertebral fractures at the age of 12 years. She manifested lower serum 25OH-D levels and were associated with lower LS-aBMD Z-scores with higher urinary bone turnover indexes (urinary NTX/Cr). OUTCOMES: Lysosomal storage diseases (LSD) have a strong correlation with the development of osteoporosis. LSD causes skeletal abnormalities results from a lack of skeletal remodeling and ossification abnormalities owing to abnormal deposition of GAGs (impaired degradation of glycosaminoglycans ) in bone and cartilage. 3D reconstruction CT scan of the spine showed diffuse hyperostosis of almost the entire spine (begins at the level of T4- extending downwards to involve the whole thoraco-lumbar and upper part of the sacrum) with total diffuse fusion of the pedicles, the transverse and articular processes, the laminae and the spinous processes. LESSONS: This is the first clinical report of adult patient with a history of osteoporosis and fractures with the late diagnosis of Galactosialidosis. Osteogenesis imperfecta (autosomal dominant and recessive) were the first given diagnoses which proven negative. The pathophysiology of the spine ankylosis in our current patient and its correlation with LSD, antiresorptive medications, vitamin D3 and supplemental calcium is not fully understood. Therefore, further studies are needed to elucidate this sort of correlation.

Surgical treatment of hip ankylosis due to heterotopic ossification secondary to spinal cord injury. / Cirugía de la anquilosis de cadera por osificación heterotópica secundaria a lesión medular.

OBJECTIVES: To expose our experience in the diagnostic and surgical treatment of neurogenic heterotopic ossification of the hip. MATERIAL AND METHODS: We designed an observational retrospective descriptive study including 20 patients (30 hips) with neurogenic heterotopic ossification of the hip secondary to spinal cord injury attended in our institution in the last 10 years, with a minimum of one year follow-up. Medical files and imaging studies were reviewed. The study variables analyzed were: type and localization of neurogenic heterotopic ossification, pre-post excision range of motion, level and aetiology of spinal cord injury, ASIA score, smoking history, surgical approach and complications associated with surgery. RESULTS: A total of 20 patients were treated with resection of heterotopic ossification in 30 hips. 16 patients presented ASIA A spinal cord injury and 4 ASIA B spinal cord injury. Preoperatively all the patients had severe ankylosis in the hip that made sitting in a wheel chair and activities such as repositioning and hygiene difficult. The average postoperative motion at the follow-up evaluation was 90° in flexion, 20° of internal rotation and 40° of external rotation. Immediately after surgery all the patients followed a specific intensive physiotherapy regime for the hip and celecoxib 200 mg was administrated daily orally for a month to prevent recurrence of heterotopic bone formation. None of the patients reviewed suffered a recurrence of heterotopic bone formation. CONCLUSIONS: Surgical excision of hip ossification in order to achieve functional ROM of the hip is the best treatment for patients with neurogenic heterotopic ossification of the hip.

A Triad of Temporomandibular Joint Ankylosis, Mandibular Retrognathia and Severe Obstructive Sleep Apnoea: Case report.

The surgical management of paediatric patients with temporomandibular joint (TMJ) ankylosis, mandibular retrognathia and obstructive sleep apnoea (OSA) is challenging. We report a nine-year-old boy who presented to the Department of Oral Health, Sultan Qaboos University Hospital, Muscat, Oman, in 2016 with complaints of limited mouth opening, loud snoring and excessive daytime sleepiness. He was diagnosed with TMJ ankylosis, mandibular retrognathia and severe OSA. The patient initially underwent mandibular distraction and, subsequently, release of the TMJ ankylosis and rib graft reconstruction. The overall patient outcome was successful, with improvement in OSA-related symptoms, good facial symmetry and adequate mouth opening.