Congenital cheek teratoma with temporo-mandibular joint ankylosis managed with ultra-thin silicone sheet interpositional arthroplasty
A 4-year-old girl presented with progressively decreasing mouth opening since birth and facial deformity. According to the parents, at birth there was a large soft-tissue mass involving the entire right cheek with restricted mouth opening, which was excised at 6 months of age when biopsy confirmed it to be a mature teratoma. Decrease in mouth opening continued even after surgery, with hypertrophy of the right infraorbital region.\nOn examination, a large cheek scar with loss of subcutaneous tissue severely restricted mouth opening (inter incisor distance < 3 mm) and maxillary hypertrophy in the infra orbital region were observed []. Oral hygiene was poor with absence of anterior teeth in both upper and lower jaw.\nComputed tomography face revealed loss of joint space, bony ankylosis between the coronoid process and zygomatic process of the maxilla with hypertrophy of infraorbital rim and the adjoining zygomatic arch [].\nChild underwent exploration of the facial skeleton using the previous preauricular scar. All soft-tissue adhesions between the cheek skin and the mandible were excised. Articular ankylosis had a fibrous component. Coronoidectomy was done to release the bony block between the infra orbital rim, zygomatic arch and the mandible with dramatic improvement in mouth opening []. After ensuring adequate mouth opening the hypertrophied malar prominence was shaved to ensure facial symmetry. As there was extensive scar tissue around the malar region most probably due to previous surgery, ultra-thin silicone sheet was used as an inter-positional material instead of standard temporalis muscle flap.\nAfter complete transaction of the ankylotic bone, the gap was kept bare enough so as to pass 0.2 mm ultra-thin silicon sheet of size 5 × 5 cm []. Medially, it was anchored with 3-0 nylon to medial pterygoid muscle and laterally to periosteum of zygomatic arch so as to fix the sheet securely and also to cover the two transacted bone ends completely.\nPost-operatively child was put on extensive physiotherapy using an acrylic dynamic jaw exerciser [ and ]. After 6 months of follow-up child has painless jaw movement with 2.5 cm inter incisor distance. Child is now planned for further refinement of facial contour.