Retromandibular Approach Research Articles

Evaluation of the transparotid retromandibular approach for the treatment of mandibular condyle fractures: analysis of clinical cases

d doi:10.1016/j.ijom.2011.07.022 doi:10.1016/j.ijom.2011.07.023 0 omparative study of 2 surgical reatment philosophies for andibular fractures . Fuenzalida Kakarieka1,∗, . Laissle Casas del Valle 1, . Vargas Farren1,2,3, . Gonzalez Mora2, . Pedemonte Trewhela2,4 Cirugia Oral y Maxilofacial, Universidad ayor, Santiago, Chile Cirugia Maxilofacial, Hospital Mutual de eguridad, Santiago, Chile Cirugia Maxilofacial, Hospital de arabineros de Chile, Santiago, Chile Cirugia Maxilofacial, Clinica Las ondes, Santiago, Chile

Poster 77: Treatment of Mandibular Subcondylar Fractures: A Retrospective Study

The purpose of this study was to evaluate treatment outcomes following closed versus open repair of mandibular subcondylar fractures in terms of functional, radiographic, and esthetic parameters. A retrospective chart review of patients who presented with mandibular subcondylar fractures was conducted at Truman Medical Center, Kansas City, MO between January 2004 and August 2010. We reviewed patient demographics (gender, age, and pertinent co-morbidities), physical exam findings, imaging studies, intra-operative findings, and follow-up exam findings. Our dataset included 193 patients, with a mean age of 29 years. Most common etiology for subcondylar fracture was assault (n=117 [61%]). Majority (n=148 [77%]) of subjects were male. Half of all fractures (n=97 [50%]) occurred on the left and 71 (36.8%) on the right right side, with remaining 22 (11.4%) being bilateral subcondylar fractures. Only 65 (33.7%) of the fractures were isolated subcodylar fractures and the rest coexisted with concomitant fractures of other parts of mandible. Fracture dislocation was observed in 76 (39.3%) of all cases. Total of 51 (26.4%) of these fractures were treated via open reduction with internal fixation via retro mandibular approach, and 105 (54.4%) were reduced in a closed fashion via guiding elastics for a period of 4 to 6 weeks. The remaining 37 (19%) were not surgically treated due to excellent occlusion. Most common post-operative complication was patient's pain perception (n=17 [8.8%]), malocclusion (n=11 [5.7%]), deviation of mandible upon mandibular opening (n=9 [4.7%]), and temporomandibular joint noises (n=8 [4.1%]). Among cases treated with ORIF, 4 (7.8%) experienced transient neurosensory deficit, 2 (3.9%) had post-operative infection, and 1 (1.96%) developed condylar resorption. None of the patients experienced ankylosis of TMJ or nonunion of the fracture; however, 3 (5.9%) patients required revision surgery due to infection. Open reduction and rigid internal fixation when indicated appears to be the suitable treatment modality in successful treatment of mandibular subcondylar fractures with minimal morbidity leading to early functional recovery.

Retroparotid Transmasseteric Approach to Condylar Fracture Through Mini-Retromandibular Access

Statement of the Problem: The incidence of condylar fractures amongst mandibular fractures is between 17.5% and 52%. Almost 50% of condylar fractures have other associated fractures and 80% of them are unilateral fractures. Most are not caused by direct trauma but from indirect forces transmitted to condyle from elsewhere. Broadly there are 2 types of fractures, intracapsular and extracapsular, but for diagnostic and practical reasons it has been divided into 3 categories: condylar head (intracapsular), the condylar neck (extracapsular) and the subcondylar fractures. They are classified as: undisplaced, deviated, displaced (with medial or lateral overlap) and dislocated. The management of mandibular condylar fractures remains controversial. A wide spectrum of management is seen from plain analgesic, to physiotherapy, intermaxillary fixation and open reduction with internal fixation. Over the past decade better understanding of biological considerations of condylar fractures, improved surgical facilities and skills have tilted the balance in favor of open reduction. Open reduction is usually carried out by extra-oral approach such as preauricular, submandibular and retromandibular. Various modifications have been proposed for retromandibular approach like transparotid, transmasseter, high cervical transmasseteric anteroparotid, and mini retromandibular. This talk will present our experience with the retro-parotid transmasseteric approach to condylar fractures through mini-retromandibular access. This approach minimizes nerve injury and provides good access.

A clinical study on the retromandibular approach for reduction and fixation of mandibular condylar fractures

A clinical study on the retromandibular approach for reduction and fixation of mandibular condylar fractures

Surgical Complications of Mandibular Condylar Fractures

The purpose of this study was to retrospectively evaluate the complications of 58 patients who underwent surgery for mandibular condylar process fractures. Data were collected from patients during a 10-year period (1999-2009). The data recorded included demographic data, etiology, diagnosis, type of condylar fracture, surgical approaches, and postoperative complications. A total of 58 underwent surgery for reduction of the condylar fractures. There were 22 patients with bilateral condyle fractures and 36 patients with unilateral condyle fractures, accounting for 65 surgeries. In 8 fractures, a preauricular approach was performed to access the fractures condyle, whereas the retromandibular approach was performed in 57 fractures. There were 2 temporary facial palsies, 1 permanent facial palsy, and 1 sialocele. There were no cases of hypertrophic scar, Frey syndrome, or salivary fistula. In conclusion, permanent deformities after surgical complications were unusual, and the results are acceptably safe.

Combined Surgical Approach Retromandibular and Intraoral to Subcondylar Mandibular Fractures

Condylar and subcondylar fractures are very common and account for at least one third of all mandibular fractures. In literature, little agreement exists about the management of extracapsular condylar and subcondylar fractures in adults. Some studies provide better results of occlusion, masticatory function, mouth opening, and bone morphology with surgical treatment. Conversely, other studies report excellent results with conservative treatment avoiding complications such as facial nerve injury and unsightly scar. In this study, we report our experience of 25 condylar/subcondylar fractures. We report the case of a man with bilateral subcondylar fractures treated by a double surgical approach, intraoral and retromamdibular. Intraoral approach lets us dissect the masseter and disconnect the temporal muscle tendon, thus favoring further reduction of fracture stumps, whereas retromandibular approach favors a good operative field and the positioning of titanium microplate. Postoperative monitoring reported good results of occlusion. Postoperative computed tomographic scans show the good reduction and positioning of titanium miniplate.

The Perilobule Approach to Subcondylar Fractures

Several approaches to the management of subcondylar fractures have been used, including the submandibular approach, the preauricular approach, and the retromandibular approach. Although they provide excellent access to repair fractures of body, ramus, and condyle, we have found it difficult to manage subcondylar fractures using either of these approaches. We describe a novel approach for subcondylar fractures that provides direct access to the fracture site. A total of 17 consecutive patients underwent open reduction and internal fixation of their subcondylar fractures using this technique. The incision line is located just anterior and posterior to the ear lobe, and is comprised of lower part preauricular and upper retroauricular incisions. Intraoperatively, the method applied shortened the time necessary for and simplified the procedure of reduction and osteosynthesis. The postoperative course was uneventful in most patients. Radiologic follow-up revealed correct reduction and fixation in all the cases. There were no occlusal disturbances, no trismus, no lateral deviations of the mandible, and no nerve lesions. Our findings indicate that the short perilobe approach is an easy and safe technique for displaced subcondylar fractures.

Epithelial-myoepithelial carcinoma on the superficial lobe of the parotid gland: a case report

Epithelial-myoepithelial carcinoma (EMC) is a low-grade malignant salivary gland neoplasm that was first described in 1972. EMC occurs in the older age group, there is a female predilection and mainly involves the parotid gland. Most authors recommend superficial parotidectomy as a treatment for low-grade malignant tumor in the superficial lobe of parotid gland. The treatment of epithelial-myoepithelial tumors typically includes surgical excision aimed at achieving a R0 resection. This paper reports a case of EMC of the parotid gland treated only by a conservational surgical excision. The lesion was exposed by the retromandibular approach and detached. After the parotid gland envelop was exposed, the mass was observed and was easy to remove due to capsulation. The preoperative diagnosis was a pleomorphic adenoma on the left parotid gland. The tumor was removed surgically with a conservative extracapsular dissection. The postoperative diagnosis was EMC, so superficial parotidectomy or radiation therapy was considered. Nevertheless, the patient was observed and no additional treatment was attempted because the patient was old and a successfully excision of the tumor had been achieved.

Management of Mandibular Sub Condylar and Condylar Fractures Using Retromandibular Approach and Assessment of Associated Surgical Complications

To evaluate surgical complications associated with open reduction and internal fixation of condylar fractures using retromandibular approach in terms of intraoperative and postoperative complications. Ten patients with displaced unilateral/bilateral condylar fractures were selected for the study. Intraoperative complications were evaluated in the form of haemorrhage due to damage to retromandibular vein and damage to marginal mandibular branch of facial nerve. Postoperative complications like presence of infection, signs of Frey's syndrome, parotid fistula formation, facial nerve palsy, and discrepancy in occlusion and functions of temporomandibular joint were evaluated at intervals of 24h, one week, six weeks and three months postoperative. Radiographically, the approximation of fracture fragments, plate fracture and screw loosening on orthopantomograph and Reverse Towne's view were evaluated at intervals of 24h, six weeks and three months postoperatively. None of the patients suffered from any major complication intra and post operatively. Open reduction and internal fixation should be given due consideration in the management of displaced mandibular condylar fractures and is associated with minimal morbidity using retromandibular approach.

Retromandibular approach for reduction and fixation of mandibular condylar fractures: A clinical experience

This study evaluated the efficiency and safety of a retromandibular approach to reduce and fix displaced condylar fractures. The study group included 31 patients who had undergone surgery for 35 condylar fractures (8 bilateral, 23 unilateral). Consultants and residents had performed the procedure. Inclusion criteria were: patient's choice for open reduction and fixation; displaced unilateral condylar fractures with occlusal derangement; bilateral condylar fractures with anterior open bite. Restriction of lateral movement towards the unaffected side was observed preoperatively in all cases taken up. There was a difference in the lateral movements towards the fractured side (mean 7.2) and unaffected side (mean 4.2) during the first postoperative review. Functional occlusion identical to the preoperative occlusion and good reduction of the condyles was noted in all cases. Facial nerve was encountered in 6 cases (17%) intraoperatively. There was one case (3%) of temporary facial nerve weakness, which resolved within 2 weeks. There was no permanent facial nerve damage in any patient. The retromandibular-transparotid approach seems to be a safe and efficient method for reduction and internal fixation of condylar fractures with little or no risk to the branches of facial nerve.

Giant, Deep Parotid Lobe Tumor: A Challenging Surgical Case

Background and Aim: Parotid tumors are relatively frequent, representing approximately 2% of all tumors in the neck area. The pleomorphic adenoma is usually found in the superficial lobe of the parotid gland, whereas deep lobe involvement is relatively rare. However, such tumors involving the deep parotid lobe may present with a neck mass that may have an intraoral extension (sometimes a dumb-bell mass). The surgical approach depends on size and location of the tumor and may be transoral, cervical, transmandibular, transparotid, retromandibular approach, or a combination.

A comparative evaluation of rhytidectomy versus retromandibular approach for Open Reduction and Internal Fixation (ORIF) of mandibular condylar fractures

This clinical study was carried out on thirty patients who underwent open reduction and internal fixation for condylar fractures via rhytidectomy/retromandibular approach were evaluated. Group I (rhytidectomy approach) were compared and evaluated clinically and radiologically with Group II (retromandibular approach) for the following parameters like surgical access, duration of surgery, anatomic reduction assessment with relevant radiographs, occlusal discrepancies, need for post operative IMF, facial nerve morbidity, other post operative complications and scarring. There was a statistically significant difference between the two groups in the duration of surgery which was found to be significantly lesser for group II than group I. Access was better in group I. Scar was well camouflaged in patients of Group I when compared to group II. The rhytidectomy (Face-lift) incision which we have used in our study has all the advantages of the retromandibular approach with an added advantage of a less conspicuous scar and a wider exposure of the fracture site. The only disadvantage is the added time required for the closure which is not a concern as the aesthetic outcome of this technique is superior to the other approaches.

Application of Modified Retromandibular Approach Indirectly From the Anterior Edge of the Parotid Gland in the Surgical Treatment of Condylar Fracture

To introduce a new surgical approach for open reduction and internal fixation of condylar fracture. In this study, 36 patients with condylar fractures (51 sides) and those of the mandibular ramus and coronoid process were treated using a modified retromandibular approach indirectly from the anterior edge of the parotid gland. The degree and type of mouth opening, occlusal relationship, facial nerve function, and other complications in the patients were assessed and evaluated. During the follow-up conducted over 12 to 24 months, x-ray examinations revealed good fracture healing. The occlusal relationship and degree and type of mouth opening improved significantly over those before operation. During the final follow-up at 24 months, no case of ankylosis and/or salivary fistula was observed. Major complications at 1 week postoperation included temporary injury to the facial nerve branches in 4 cases; this condition improved after 1 to 3 months. Open reduction and internal fixation of condylar fracture by using the modified retromandibular approach indirectly from the anterior edge of the parotid gland has many advantages. Compared with the traditional surgical incision, this method is simple and short, and the completely exposed operative field facilitates reduction and fixation. Compared with transparotid approaches, it substantially reduces the risk to the facial nerve. At the same time, this method is not only suitable for the surgical treatment of condylar fractures but also for those of the mandibular ramus and coronoid process.

O.455 Postoperative use of intremaxillary flxation devices

The aim of this study was to evaluate the safety, utility and morbidity associated with the treatment of mandibular subcondylar fractures using the retromandibular transparotid approach and to evaluate the stability of a single 2 mm miniplate fixation system for such fractures. Forty-two cases with 48 mandibular subcondylar fractures were analysed prospectively for 12 months and evaluated for functional results, scar, postoperative complications and stability of fixation. There were three cases of suboptimal occlusal status, two cases of haematoma that were drained and resolved, eight patients with facial nerve weakness which resolved in a few weeks, and three cases of salivary fistulae that resolved after treatment. All cases showed stable osteosyntheses. Maximal postoperative interincisal distance was 32–61 mm (mean 44 mm). Four patients had deflection on opening, while clicking on opening or chewing was observed in five patients. The postoperative scars were well accepted by all patients. The results of this study suggest that a retromandibular approach will facilitate accurate reduction and fixation of subcondylar fragments with a good cosmetic result and minimal complications. A single 2 mm miniplate fixation provides stable results.

P.274 Airway obstruction following unilateral fracture of mandible

The aim of this study was to evaluate the safety, utility and morbidity associated with the treatment of mandibular subcondylar fractures using the retromandibular transparotid approach and to evaluate the stability of a single 2 mm miniplate fixation system for such fractures. Forty-two cases with 48 mandibular subcondylar fractures were analysed prospectively for 12 months and evaluated for functional results, scar, postoperative complications and stability of fixation. There were three cases of suboptimal occlusal status, two cases of haematoma that were drained and resolved, eight patients with facial nerve weakness which resolved in a few weeks, and three cases of salivary fistulae that resolved after treatment. All cases showed stable osteosyntheses. Maximal postoperative interincisal distance was 32–61 mm (mean 44 mm). Four patients had deflection on opening, while clicking on opening or chewing was observed in five patients. The postoperative scars were well accepted by all patients. The results of this study suggest that a retromandibular approach will facilitate accurate reduction and fixation of subcondylar fragments with a good cosmetic result and minimal complications. A single 2 mm miniplate fixation provides stable results.

Mini-retromandibular approach to condylar fractures

Among maxillofacial surgeons, a general agreement exists that the therapeutic strategy for intracapsular condylar fractures is conservative, while the treatment of extracapsular fractures of the mandibular condyle is extremely controversial. The indications and choice of treatment are less than uniform, often relying on the surgeon's personal experience and beliefs. The literature increasingly suggests that the surgical management of these fractures is superior to conservative management in functional terms. Nonetheless, the indications for surgically treating condylar fractures are limited by fear of potential pitfalls related to the access. Extraoral routes to the condyle involve the risk of facial nerve injuries or visible scars; transoral access is free from these pitfalls but is demanding technically, especially for higher neck fractures. In our experience, a 2-cm-long retromandibular access allows straightforward management of condylar fractures, providing as a result a well concealed scar. From 2006 to 2007, 21 patients with 25 condylar fractures were treated surgically using the mini-retromandibular access. The mean operating time was 32 min (range 17-55 min). No facial nerve injuries were observed. The first two patients developed postoperative infections. One patient, in whom the first intervention resulted in malreduction of the fracture because the access was insufficient (15 mm incision), required a second operation to achieve correct reduction and rigid fixation of the condyle. In all cases, good anatomical stump reduction was achieved. All the patients obtained good articular function, since the access was exclusively extra-articular. Condylar fracture reduction, fixation and healing can be managed comfortably using a limited retromandibular approach. Moreover, the risk of facial nerve injury is limited as the nerve fibres are viewed directly.

Tratamento cirúrgico das fraturas subcondilares: avaliação da abordagem retromandibular de hinds

OBJETIVO: Avaliar retrospectivamente os resultados dos procedimentos terapêuticos cirúrgicos, através da abordagem retromandibular de Hinds, no tratamento das fraturas subcondilares. MÉTODO: o protocolo foi observacional, transversal, retrospectivo com inclusão de 31 casos divididos em quatro grupos, de acordo com a lateralidade, desvio da fratura e associação de fraturas em outros sítios. O sucesso terapêutico foi classificado de acordo com a necessidade de tratamento fisioterápico e bloqueio, permanência de desvios ou lateralidade de abertura bucal, amplitude reduzida de abertura bucal (menos de 40 mm), presença de dor moderada à intensa ou ausência de redução da fratura e instabilidade da osteossíntese. Para avaliação dos fatores determinantes de sucesso foram incluídas as variáveis: gênero, idade, causa da fratura, lateralidade, desvio, fraturas associadas e localização das fraturas. O método estatístico utilizou tabelas de associação cruzada com análise pelo teste não paramétrico do qui-quadrado. Em todas as situações foi arbitrado um valor de significância de 5% (p< 0,05). RESULTADOS: Encontrou-se uma resposta de sucesso total em 19 casos (61%) e sucesso parcial em 12 casos (39%). Não foram encontradas associações entre a resposta cirúrgica e as variáveis gênero, idade, causa da lesão e presença de fratura associada. Os casos com desvios laterais e bilateralidade da lesão obtiveram maior freqüência de sucessos parciais. CONCLUSÃO: Na amostra estudada, a abordagem retromandibular de Hinds para o tratamento das fraturas subcondilares, na maioria dos casos, teve sucesso total após o procedimento.

Abordaje retromandibular para reducción de fracturas subcondilares

AbstractFractures of the jaw are the second ones in order of frequency, being the condylar region the most frequent. With the coming of the rigid fixation, more surgeons now agree with the open approach for the displaced fractures of subcondylar region, specially in adult patients. When a rigid fixation is necessary, retromandibular approach is an effective and safe technique, specially for condylar displaced fractures, in which the facial nerve is exposed without any damage.

The periauricular transparotid approach for open reduction and internal fixation of condylar fractures

Treatment of fractures of the mandibular condyle fractures varies among centres as there still is no general consensus. The aim of this paper was to determine the safety and efficiency of surgical treatment using a transparotid approach for direct plating. A prospective clinical study was conducted on 34 patients with 36 fractures of the condyle. All 36 fractures were displaced, and 14 (39%) of them were fracture dislocations. The fractures were treated surgically with a transparotid facelift or retromandibular approach using miniplates and screws for fixation. Patients were carefully followed up and were asked to answer a survey paper 2-39 months postoperatively. Occlusion practically identical to the pretraumatic condition was achieved in 31 out of 33 dentate patients (94%). Postoperative interincisal distance was 30-61 mm (mean 44 mm), 4 patients (12%) had postoperative deflection to the side of injury during mouth opening. Facial symmetry was achieved in all of the patients. Eight out of 36 cases (22%) had a transient weakness of certain ipsilateral facial muscle groups, lasting for 4-8 weeks. In one of these patients, a mild weakness of the upper lip and lower eyelid persisted after 13 months. There were 5 cases of miniplate fractures (14%), all of them in patients in whom 1.7 or thinner miniplates were used. There were 5 cases of salivary fistulae (14%), all of them in patients where the parotid capsule was not closed in a watertight fashion. According to the postoperative survey completed by 32 patients, 30 of them (94%) were very satisfied with the outcome of treatment. If conducted properly, the transparotid facelift approach offers a safe and effective approach for direct fixation of condylar fractures.

Retromandibular approach to the mandibular condyle: a clinical and cadaveric study

This prospective study was carried out to assess the morbidity of the retromandibular approach in the management of condylar fractures. Twenty consecutive patients underwent open reduction and internal fixation of their condylar fractures using this technique. Branches of the facial nerve were encountered in six cases (30%). Temporary weakness of the facial nerve occurred in six patients (30%), but this resolved in all cases within 3 months and there were no cases of permanent nerve injury. Two patients had a temporary deficit of the great auricular nerve and one patient developed a sialocoele that resolved with aspiration. A cadaveric study using 30 facial halves (15 fresh cadavers) was also conducted. Branches of the facial nerve were encountered in 12 dissections (40%). The literature regarding facial nerve morbidity in relation to the management of condylar fractures is reviewed.