 ಎನ್್але ಮಂತಮಲಾ ನಗ ಅದಾರ solution, ರೈಸಿು ಮಸಿ ಜನೃಣ೉ಸಿ ಕೀಕಂಟ್ ಅದ leva � finally,ಕೋ ಬಿವಾಪ � adonse ಇಾರೋರೆಝ್ ಲೈದಲ್ಲಿಲೆ ಲ್ಲಿಲಿಲೆ ಯಕಿಲಿಲಿಲಿ ಹಾಶ೓ನುವ್ಲಿಲ್ಲಿಲ ರೋಿಲ್ಲಿಲ್ಲಿಲಿಲ್ಲಿಲ್ಲಿಲ್ಲಿಲ್ಲಿಲಿ ವಿರೆಡಿಲ್ಲಾಲೆಯಾಲಿಲುಲಿಲಾ� value boostingಣಾರಾಷಿ ಆಯದಿವೆ ಹಳ and complaining saying that the child is unable to thrive and has significant difficulty in having his food. So when I saw the child at the first instance, what crossed my mind was the child had bilateral TMJ ankylosis. So what we decided then was since there was least amount of bone stock available, I initially planned for a distraction osteogenesis. Which stems from the principle of our orthopedic colleagues where distraction osteogenesis was laid down by Elizaro. So we used the principles of distraction osteogenesis and did a bilateral distraction osteogenesis for the child so that we could grow the mandible in a vertical as well as an antiropostida direction subsequent to which the child did well and then the patients came back to me post distraction they didn't come back to me for a long time possibly because of financial issues and one fine day they landed up in my OPD the boy whom I had operated at the age of 3 to 4 years had now come back to me at the age of 15 years now the other question at this stage the parents had asked me was once you resect the mandible or once you release the ankylosis what are you going to interpose or what are you going to put there so I told them the same thing we would go in and resect the mandible or release the ankylosis and then give them a mouth opening but also I warned them saying that there is a possibility of a repeat or a re-ankylosis at this time what crossed my mind was why not a temporomandible adjoint prosthesis when you look back into literature many people wouldn't agree with me saying that temporomandible adjoint alloplastic reconstruction is a contra indication for skeletally immature individuals so what we ended up doing was we ended up doing a temporomandible adjoint prosthesis for the baby and these are the STL models what we have used to assess the child's ankylotic mass and if you see here predominantly the ankylotic mass is significantly bigger on the left side and you see the elongated coronoid process of the mandible as well and simultaneously when you have a look at the right side the condyle on the right side is not different but definitely there is some amount of fibrotic adhesions or a fibrous ankylosis so what we did was we never went into correcting the facial asymmetry which is very evident on the right side whereas fullness on the left side was we only planned for ankylosis release on the left side and then giving back the patient his mouth opening and then address the deformity at a second stage as there was limited amount of soft tissue on this side we planned to do the soft tissue stretch and only augmentation on the right side as a secondary procedure so what we ended up doing was we released the TMJ ankylosis and then we went in with an alloplastic joint prosthesis this is a prototype of the same patient where we have gone in and replaced the temporal mandible joints with the chromium cobalt molybdenum alloy kind of prosthesis and here is the prototype which is manufactured to understand where the joints would come in and that's the fossa iminence prosthesis which is here what additions we have done for these kind of patients is that I have given a bare hug on this fossa prosthesis the bare hug helps us to identify as to what is the seating and here you see when you look at this particular joint prosthesis there are bare hugs on the inferior and the posterior border so this concept of bare hug is something which helps us design and understand what is the ideal position for the joints and once we release the ankylotic mass that was the final position of the TJR or the total joint prosthesis yes I would agree that there is certain amount of facial asymmetry which is still existing the parents all they wanted was that the child should function well eat well and thrive well and I too would agree with the patient related outcomes that his dietary score improves and that's the total joint prosthesis in place for you today when the patient visited to a row PD he's put on weight he's looking good and I've convinced the parents for a second state surgery for a soft tissue augmentation rather than a bony surgery because they're not very keen on it for them what mattered was the mouth opening and eating well which the patient has got back and there is significant improvement in quality of life as well as from the patient's point of view or the patient related outcomes the patient is doing well thank you so much for your patient listening we shall get back to you once again with interesting cases at Kasturba Medical College Hospitals Ambedkar Circle, Mangalore thank you