Deep Subfascial Approach as an Alternative to Explore Temporomandibular Joint: A Pilot Study

Abstract

Statement of the problemThe study aimed to compare the efficacy of superficial, subfascial, and deep subfascial approaches in patients with temporomandibular joint (TMJ) disorders and to correlate its effect on facial nerve function and quality of the surgical field. Materials and methodsThe study comprised of 15 cases indicated for TMJ surgery divided randomly into 3 study groups: Groups I, II, and III based on the surgical approach used (Figure 1). In Group I patients, the superficial approach was used and dissection was limited to the superficial layer of temporalis fascia. In Group II, a subfascial approach was used where dissection was carried between the 2 layers of the fascia. In Group III, a deep subfascial approach was used where dissection was kept between the deep layer of fascia and muscle. Intraoperatively, the quality of surgical field was assessed using Fromme, et al. Scale and intraoperative blood loss were calculated for each group. The dissection time was measured as the time elapsed from the skin incision to reach the dissection plane. All patients were evaluated for pain and swelling on the first, third, and seventh postoperative day. The facial nerve function test was performed post-surgically after 24 hours, 1 week and 1, 3, and 6 months using the House-Brackman scale. Methods of data analysisStatistical analysis was performed using SPSS software (IBM Corp, Armonk, NY). Data were presented as mean and appropriate. Statistical tests were applied. ResultsThe inter-group comparison showed that the outcomes of all intraoperative parameter were superior in Group II in comparison to the other groups (Table 1), whereas postoperative pain and swelling and facial nerve function were better in Group III (Table 2). Outcomes dataThe mean time required for exposure of TMJ was least in Group I as compared to the other groups (mean score for Groups I, II, and III, respectively, 20.8 ±1.36;19.0±3.3.17; and 29.2±4 minutes). The quantity of blood loss was minimum in Group II (mean score for Groups I, II, and III, respectively, 311.8±5.15; 244.4 ±6.19; and 249.6±10.58). Similarly, the quality of the surgical field was highest in Group II (mean score for Groups I, II, and III, respectively, 2.2±0.87;1.00±0.44; and 1.04±0.33). Mean pain scores were generally better for Group III when compared to Groups I and II on all days. Highest mean score observed on the first postoperative day was 5.2±1.33; 6.2±1.17; and 4.8±1.16 for Group I, Group II and Group III, respectively. It was also observed that deep subfascial approach resulted in lesser postoperative swelling as compared to the other groups (mean score for Group I, Group II, and Group III, respectively, at seventh postoperative day was 27.2±1.13;22.1±0.86; and 20.14±2.09). At 6 months, all surgical sites in Group III had normal facial nerve function, whereas total palsy of temporal branch was seen in 1 case for Group I and mild dysfunction was noted in 1 case of Group II (Figure 1). ConclusionThe deep subfascial approach is the safest approach among the preauricular approaches to avoid injury of the facial nerve and yielded better postoperative result for pain and swelling. However, the traditional subfascial technique provided a quicker and blood-less field of dissection. Thus, either of the 2 approaches could be used depending on the surgeon's preference and training.