Submandibular Approach Research Articles

Less-Invasive Technique for Non-stabilized Mandibular Fracture in Mouse Models.

Non-stabilized fractures can be made at mandibular sites in mice, thus making it possible to analyze bone repair using an endochondral ossification mode. To most accurately reflect this process in vivo, it is necessary to have a standardized protocol to avoid excessive bone loss and soft tissue damage, particularly at the mandibular site, an anatomical site characterized by minimal access. To our knowledge, we describe for the first time a less-invasive protocol of non-stabilized mandibular fracture in mice. Adult mice are anesthetized with isoflurane and receive a preoperative dose of buprenorphine by subcutaneous injection. A submandibular approach is performed, with a skin incision made along the inferior border of the mandible. The masseter muscle is elevated in a subperiosteal plane along the mandibular ramus with a periosteal elevator. A vertical and complete fracture of the ramus is performed from the basilar border to the coronoid notch (between condylar and coronoid processes), using a piezoelectric bone surgery device under saline serum irrigation at the basilar edge and scissors to complete the fracture of the mandibular ramus. The skin approach is closed by silk sutures. This detailed procedure for non-stabilized mandibular fractures offers an efficient procedure allowing minimal bone loss and soft tissue damage. This technique ensures successful and consistent results to accurately reflect the process of endochondral bone repair in mouse models.

Submandibular Approach to the Mandible (Cadaver)

The submandibular, or Risdon approach, is an extraoral approach for treating fractures of the mandibular body and angle. Despite the fact that the intra-oral approach has been used recently for open reduction and internal fixation, the submandibular approach is applied to more difficult fracture patterns such as comminuted, atrophic, and defect fractures. This approach allows better manipulation of the fragments, good control of the lingual cortex and inferior border, and application of selected hardware. Here we demonstrate how to perform a submandibular approach in a cadaver.

Modified Preauricular Transparotid Approach for Treating Mandibular Condylar Fractures.

We introduce a technical variant of the standard preauricular approach to treat intracapsular and condylar neck fractures: the modified preauricular transparotid approach (MPTA). The main modification, when compared with the conventional submandibular approach, is that the incision of the superficial musculoaponeurotic system is performed directly above the parotid gland, and the buccal branch of the facial nerve is dissected in a retrograde way within the parotid gland. Between January 2019 and December 2020 at the Maxillofacial Departments of "Ospedale Maggiore" of Parma and "Policlinico San Martino" of Genoa 6 patients affected by intracapsular and condylar neck fractures underwent open reduction and internal with MPTA. Surgery was uneventful in all patients; no infections occurred in any of the cases; the mean procedure duration was 85 minutes, ranging from 75 to 115 minutes. At the 1-year follow-up, all patients had stable occlusion with a natural, well-balanced morphology of the face and adequate dynamic excursion of the mandible. MPTA is particularly suited for intracapsular and condylar neck fractures. Morbidity is negligible in terms of damage to the facial nerve, vascular injuries, and esthetic deformity.

Misplaced Pterygoid Implant removed following Surgical Exploration

A 62-year-old male patient had reported to our department with a history of pterygoid implant placement in the right maxillary region. The referring dentist had updated us about the possibility of a misplaced implant. The patient was anxious but showed no clinical signs of discomfort or pain. A CT scan with contrast was done to check for the location of the implant and also visualize the proximity to any vital structures. The CT study revealed an implant seen in the right parapharyngeal space closely abutting the internal carotid artery. The screw of the implant was sharp and since it was closely abutting the internal carotid artery it warranted removal at the earliest. An endoscopic approach was discussed with the ENT surgeons but due to the size of the implant and limited access through the antrum we had to look for an alternative method. The technique of performing an access osteotomy of the maxilla would give better visualization and access to the implant but would require the maxilla to be plated and the patient who was 62 years old was not too keen on the thought of this procedure. Finally, an extraoral submandibular approach was finalized and used. Under general anaesthesia, a submandibular incision was marked and dissection was done, the carotid was first identified and taken control off in case we encountered any bleeding or injury to the internal maxillary artery while removing the implant. Dissection continued towards the mandible and the masseter was split to give access to the pterygoid region. An intraoperative C- arm showed that the implant was in close vicinity. The implant was removed intraorally via the buccal vestibule and the wound sites were closed without any complications.

A Novel Technique for Resection and Reconstruction of the Temporomandibular Joint by Sliding Vertical Ramus Osteotomy using Only Submandibular Approach.

In this paper, an innovative technique for resection and reconstruction of the temporomandibular joint by sliding vertical ramus osteotomy using only a submandibular approach is presented. Before pulling the posterior mandibular border slightly downward to expose parts of the condyle, the vertical ramus osteotomy was performed. With the help of 3D simulation and surgical templates, the condylectomy was carried out using the ultrasonic osteotome through the submandibular approach. Our technique achieved the desired results while preventing complications of facial nerve paralysis, the occurrence of Frey syndrome, and the preauricular scar. Therefore, we suggest that this surgical method represents an alternative treatment option for temporomandibular joint lesions.

RECURRENT ODONTOGENIC FIBROMYXOMA OF SUBMANDIBULAR AND LEFT TEMPORAL REGION: A CASE REPORT

Odontogenic myxofibroma (OM) is a benign odontogenic tumour of maxillofacial bone with locally aggressive behaviour. It is thought to arise from the odontogenic ectomesenchyme of dental pulp or periodontal ligament. Odontogenic myxofibroma typically presents as painless slow growing tumour with high recurrence rates ranges from 10% to 45%. A case of recurrent odontogenic myxofibroma of submandibular, left preauricular and left temporal region presented in this case report. An 11-year-old Malay girl complaint of a painless, gradually progressive firm swelling on the lower left side of the jaw for 6 months duration. On clinical examination revealed firm swelling from the left angle of the mandible to the left parasymphysis area. A dental panoramic radiograph and computed tomography (CT) scan of the head and neck showed expansile lesion at left posterior mandible causing thinning and erosion of the mandibular cortex, multiloculated with tooth germ of 38 within and displaced inferiorly. Histopathological examination revealed stellate to spindle shape cells dispersed in a myxoid background. A final diagnosis of odontogenic myxofibroma has been made. Hence, left segmental mandibulectomy with condyle disarticulation was done via a submandibular approach. Unfortunately, a year later she had recurrence at bilateral submandibular region extending to left preauricular and left temporal region associated with pain and unable to close her mouth. Multiple surgery was carried out beginning with removal of the tumour at the bilateral submandibular region followed by removal of tumour at left temple. The operations were uneventful. However, tumour excision in the left preauricular region is yet to be performed pending magnetic resonance imaging (MRI) investigation to evaluate the soft tissue extension prior to surgical planning.

The foramen ovale: a keyhole to the brain? Computer simulations of percutaneous FO punctures

BackgroundThe percutaneous cannulation of the foramen ovale (FO) is implemented in treating trigeminal neuralgia, diagnosing temporal lobe epilepsy and biopsy petroclival lesions. This study dealt with the question whether it is possible to reach intracerebral structures with a puncture beyond the Gasserian Ganglion (GG) without bone destruction or perforating vascularity.MethodsWe considered the FO a natural keyhole and performed computer-simulated punctures through the right and left FO to eight intracerebral structures. Therefore, we took the Hartel and Submandibular (SM) approach as a starting point and planned trajectories with stereotactic planning software by using brain scans of ten patients.ResultsThe simulated punctures with the Hartel approach directly reached the hippocampus (20 out of 20 trajectories), the lateral ventricle (15/20) and the amygdala (2/20). The pons was reached (20/20); however, the pontine vascularity was within the course. The trajectories to the thalamus (13/20) ran through the hippocampus or the mesencephalon. The simulated punctures with the SM approach directly reached the amygdala (18/20), the lateral ventricle (5/20) and the putamen (20/20). The trajectories to the nucleus caudatus (20/20) pierced the hippocampus, the putamen or the maxillary artery. The courses to the thalamus (7/20) ran through the hippocampus or the mesencephalon. The sinus cavernosus could not be reached with the Hartel or SM approach.ConclusionsThis study indicates that a percutaneous approach to the hippocampus, the lateral ventricle, the amygdala and the putamen is possible without harming major vessels or bone destruction. For a possible implementation of these trajectories in a clinical setting, it is necessary to prove these simulated punctures in cadaveric studies.

Minimally Invasive Mandibular Microsurgery: A Systematic Review and Meta-analysis.

All known cases of MIMMR were identified following the Preferred Reporting Items for Systematic Reviews, Meta-Analyses guidelines, and our own surgical experience. Patient demographics, MIMMR type [submandibular (SM), modified facelift/retroauricular (MFL/RA), or intraoral (IO)], methodology, and clinical outcomes were analyzed with the Fisher exact and Kruskal-Wallis tests. Forty-seven patients underwent MIMMR. Ameloblastoma was the most common pathology treated using all approaches, and MFL/RA was the only approach used to treat squamous cell carcinoma (P = 0.0103). Reconstruction was reported for large, bilateral defects only via the SM or IO approach (P = 0.0216). The iliac crest or fibula was used as a donor site. The facial artery was the most common recipient vessel using the IO and SM approaches, whereas the superior thyroid and external carotid vessels were the most common in the MFL/RA approach (P < 0.0001). Virtual planning was used in all cases performed via an IO approach, 80.0% of cases using an SM approach, and no MFL/RA cases (P < 0.0001). Good aesthetic and functional outcomes were reported for every patient, and there was no difference in complication rates (P = 0.2880). Minimally invasive approaches are safe and effective treatment options for patients requiring mandibular microsurgery, usually in the setting of benign pathology. The IO and SM approaches usually rely on the facial vessels, whereas the MFL/RA approach permits access to the superior thyroid and external carotid vessels and cervical lymphadenectomy.

The Submandibular Approach: A Descriptive Perspective of the Retropharingeal Corridor to the Craniocervical Junction (Microscopic- vs. Endoscopic-Assisted Dissections).

The craniocervical junction refers to an area from the line separating the middle and lower third of the clivus to the base of the dens (anteriorly) and from the posterior edge of the occipital foramen to the spinous process of C2 (posteriorly). Here, the clival region is a challenging surgical target surrounded by a complex neurovascular architecture. Historically, mainly the complex, and high-risk, transmucosal approaches have been the corridors of choice when targeting this region. Nevertheless, the inherent broad anatomic and pathological variants have shown the need for more-malleable and wider approaches. Thus, MacAfee's established retropharyngeal approach has been simplified in parallel to the application of endoscopic surgery, therefore providing access to the clival region through a low-risk retropharyngeal space when compared to homologous anterior transmucosal approaches. The following review analyzes the literature that has specifically described the craniocervical junction after reaching the clivus (or at least after odontoidectomy) through the retropharyngeal corridor, from the perspective of the open approach or the endoscopic submandibular approach.

Use of transoral ultrasonography technique in tongue cancer: Advantages and disadvantages

Aim. To evaluate advantages and disadvantages of transoral ultrasonography (US) in tongue cancer.Materials and methods. US was performed in 165 patients between the ages of 15 and 85 years with malignant tumors of the mobile tongue (74 (44.9 %) women, 91 (55.1 %) men).Among 165 patients, 144 had primary tongue tumor. The study also included 21 (12.7 %) patients with recurrent tumor which clinically could be represented by a true recurrence (tumor development 6 months after the end of treatment) or by continued growth (tumor development less than 6 months after the end of treatment). The study included patients with tongue tumors Т1 - 50 (30.3 %) patients, Т2 - 78 (47.3 %) patients, Т3 - 16.4 % of patients, Т4 - 6.1 % of patients.Three types of approach to tongue tumor visualization were used: submandibular, transoral, and transbuccal with a standard linear transducer (4-9 MHz) and intraoperative linear transducer (5-14 MHz). In total in 165 patients with tongue tumors, 147 (89.1 %) transoral US, 86 (52.1 %) submandibular US and 25 (15.2 %) transbuccal US examinations were performed.Results. Among 165 patients, agreement between the sizes measured using US and histological examination was observed in 142 (86.1 %) patients taking into account 15 % error.With increasing tumor thickness and, correspondingly, T criterion, increased frequency of agreement between US data and histological data was observed. Thus, for T1 stage frequency of agreement with US data was observed in 61.8 % of cases, for Т2 stage in 81.1 % of cases, for Т3 stage in 93.8 %, and for Т4 stage agreement was observed in 100 % of cases.Frequency of agreement with histological data in evaluation of tongue tumor thickness for transoral approach was significantly higher than for submandibular approach (р = 0.014). Transoral technique was more accurate for measurement of thickness of primary tumors - 80.3 % of results agreed with histological examination, and for recurrences frequency of agreement was only 33.3 %. Submandibular approach for primary tumors showed accurate measurements only in 67.6 % of cases, in recurrent tumors in 58.3 % of cases. Transbuccal approach also showed higher measurement accuracy for tumor thickness in primary patients (70.0 %) compared to recurrent tumors (40.0 %).Conclusion. Use of transoral ultrasonography significantly improves clinical staging of tongue tumors at the preoperative stage.

Transcervical Submandibular Approach: A Patient and Observer Scar Objective Score appraisal

Transcervical Submandibular Approach: A Patient and Observer Scar Objective Score appraisal

Is the retromandibular approach a suitable approach to anatomical reduction of unilateral subcondylar fracture? A non-randomized clinical trial

The aim of this study was to evaluate the efficacy of the retromandibular approach (RMA) to produce three-dimensional (3-D) reduction of the unilateral subcondylar fracture and Temporomandibular Joint (TMJ) functional implication.Methods: A prospective cohort study was designed. Twenty-nine patients with unilateral subcondylar fracture underwent consecutively Open Reduction, and Internal Fixation. The cohorts were divided into two groups; RMA group (n = 16, 55.17%) and submandibular approach SMA group (n = 13, 44.82%). The primary outcome was the anatomical 3-D reduction of the condyle. The secondary outcome was to compare the condyle position and inclination finding with TMJ outcomes. Helkimo Index score was used to evaluate the TMJ outcome at six months postoperatively.Result: There was a significant difference between the mediolateral condylar inclination, condylar medial and vertical positions when RMA compared with SMA groups (P < 0.05). The medial joint space was correlated with the medial condylar position in both groups (P < 0.05). The Helkimo Ai and Di was associated with mediolateral condylar inclination in SMG; however, Helkimo Ai was found to be correlated with the RMA group.Conclusion: The current study demonstrates that the RMA could re-establish the anatomical position of the unilateral subcondylar fracture in patients undergoing ORIF. The clinical outcome of the TMJ with RMA was better than SMA.

Intraoral versus transcervical approaches in mandibular reconstruction with free flaps: A retrospective study

This study aims to investigate the clinical and functional differences between intraoral and transcervical approaches for segmental mandible resection and reconstruction with free flaps. Patients diagnosed as benign and low-grade mandibular malignant tumors without neck dissections were retrospectively reviewed and divided into intraoral and transcervical groups. Patients of intraoral group underwent intraoral mandibulectomy and vascular anastomosis was performed through a 2-cm submandibular incision, while traditional submandibular approach was used in transcervical group. Clinical characteristics of two groups were assessed including body mass index (BMI), defect types and number of fibular segments, as well as perioperative variables such as operation time, blood loss, drainage volume. The score of appearance, swallowing and speech using the University of Washington Quality of Life Questionnaire (UW-QOL) was recorded and analyzed 6-month postoperatively.A total of 14 patients in intraoral group and 21 patients in transcervical group was collected, respectively. In intraoral group, intraoperative blood loss and postoperative drainage volume were significantly reduced in comparison with transcervical group (p = 0.0146, p = 0.0017; respectively). The score of appearance was 87.50 ± 12.97 in intraoral group, which was significantly higher than 64.29 ± 12.68 in transcervical group (p < 0.0001). Similar results were found in patients of subtype Class II mandibular defect between two groups. However, patients of intraoral group had a significant increase in operative time and a comparable amount of intraoperative blood loss (p = 0.0472, p = 0.1434; respectively).Within the limitations of the study it seems that an intraoral approach combined with a 2-cm submandibular incision should be preferred over a transcervical approach for segmental mandibulectomy and free flap reconstruction whenever appropriate.

Analysis of the High Submandibular Approach: A Critical Reapprasail of a Transfacial Access to the Mandibular Skeleton.

In 2006 following the development of dedicated osteosynthesis plates, Meyer and colleagues reported a successful clinical study of condylar fractures treated by a modified submandibular approach; it was called high submandibular approach or "Strasbourg approach." The aim of this study is to describe the high submandibular approach step by step. Between January 2010 and December 2015 at the Maxillofacial Unit of the Hospital "Policlinico San Martino" 13 patients affected by subcondylar fracture underwent open reduction and internal with high submandibular approach. Surgery was uneventful in all patients; no infections occurred in any of the cases; the mean procedure duration was 89 minutes, ranging from 66 to 125 minutes. The mean hospital stay was 2.9 days, ranging from 2 to 6 days. At the 1-year follow-up, all patients had stable occlusion with a natural, well-balanced morphology of the face and adequate dynamic excursion of the mandible. The morbidity is negligible in terms of damage to the facial nerve, vascular injuries, and aesthetic deformity. The authors think that further prospective clinical trials are necessary to assess and eventually develop this approach.

SUBMANDIBULAR LIPOMA EXCISION: A CASE REPORT

The aim of this study is to report the excision of a benign tumor of adipose tissue in the submandibular region. A 57-year-old dark-skinned male patient reported increased volume on the left side of his face, with approximately 10 years of evolution. The physical exam showed increased submandibular volume on the left side: a nodule measuring about 10 cm, with a soft and mobile consistency and painless. Fine needle aspiration puncture exam, contrast computed tomography, and ultrasound of the affected site were performed and the result was suggestive of benign tumor of adipose tissue. The patient underwent surgery by submandibular approach and excisional biopsy of the lesion was performed. The tumor presented a yellowish color, measuring 7 cm in its largest diameter. The material was sent for histopathologic examination, which confirmed the diagnosis of lipoma, a benign tumor of adipose tissue. Twelve months of follow-up showed no recurrence or complications.

EXTRAORAL APPROACH FOR THE TREATMENT OF A LARGE PROPORTIONS SIALOLITHIASIS AFFECTING THE SUBMANDIBULAR GLAND

Sialolithiasis is defined as the development of stones within the parenchyma or ducts of the salivary glands, and it frequently affects the submandibular gland duct of male adults. We report a case of sialolithiasis occurring in the submandibular gland parenchyma and its surgical treatment. A 44-year-old male patient was referred for evaluation of a painful swelling in the submandibular region with 1-week evolution. The extraoral examination revealed a volume growth in the right submandibular region. Intraorally, there were no alterations. The panoramic radiography revealed a well-defined radiopaque lesion measuring approximately 2.5 cm. The clinical and radiographic findings established the sialolithiasis diagnosis. The treatment consisted of the excision of both sialolith and the right submandibular gland due to its location in the parenchyma, under general anesthesia, using an extraoral submandibular approach. The specimen was subsequently sent to the laboratory for histologic confirmation. The patient's recovery was uneventful.

A Combined Transoral and Contralateral Submandibular Approach in the Surgical Management of Osteoradionecrosis of the Mandible With Free Flap Reconstruction

We describe a method for performing mandibular resection and vascularized tissue transfer via an intraoral and contralateral submandibular approach to minimize the risk of wound complications in a radiated field. Surgery on radiated tissue associated with osteoradionecrosis of the mandible can present with oral cutaneous fistulas, dense fibrotic skin, and altered tissue planes to make dissection through this tissue tedious and can place the marginal mandibular nerve at increased risk of injury. The use of custom plates allows surgeons to minimize incisions and depend less on anatomic/visual cues during surgery to obtain an accurate result. Our experience in 8 patients has shown a predictable method for resection and reconstruction of the mandible, while minimizing the potential complications associated with previously radiated and operated patients.

Submandibular Gland Sialocele: A Rare Complication Following Open Treatment of Mandibular Fracture

Study Design Case report. Objective A sialocele is a subcutaneous cavity containing saliva, caused by trauma or infection in the parotid or submandibular gland parenchyma, by ductal stenosis or glandular duct laceration with subsequent asymptomatic dilation and swelling. Many cases of parotid sialoceles have been published, but few cases of submandibular sialoceles occurring as a result of surgical trauma have been reported. The purpose of this article is to inform clinicians and to raise awareness about an unusual post-operative condition of a sialocele of the submandibular gland after treatment of a sequele of a mandible fracture. Methods We report a case of a 33-year-old male with a submandibular sialocele in the submandibular gland, that presented on computed tomography as a 10 × 4 × 3 cm right submandibular fluid collection in the submandibular space, and developed after an open reduction and internal fixation of a mandibular fracture through a submandibular approach. Results In the clinical case, the patient presented with sequelae of untreated fractures of the right angle and parasymphysis of the mandible. Both fractures had unfavorable deviations for 2 months, with a diagnosis of pseudoarthrosis, or non-union. In the first surgical stage, extensive debridement at the stie of non-union and precise anatomical reduction and fixation of the bone segments were performed via a submandibular surgical approach. The treatment of the post-operative sialocele occurred in a second surgical procedure, which included surgical exploration and right submandibular gland excision. No complications related to the post-operative approach were observed in a follow-up of 1 month. Conclusions Given the paucity of publications and treatment strategies for submandibular gland sialoceles in the literature, we hope to build a foundation to guide clinicians who encounter these rare adverse events. Surgeons will have a better understanding of the risks involved when they encounter cases like this, where extensive surgical debridement was necessary due to skewed consolidation and extensive pseudoarthrosis after the absence of immediate treatment following the initial trauma.

A Modified Submandibular Approach - Assessment of Outcome

The submandibular approach has been an integral tool in facial surgery since 1934. The technique is indicated in different clinical scenarios. This approach is governed by two key determinants; namely the skin tension lines and the course of the marginal mandibular branch. Aim of study: this study suggests that moving the incision further into the neck while respecting the course of the facial nerve would help achieving both optimal esthetic outcome as well as less nerve injuries. Materials and methods: eight patients requiring facial surgery, where the submandibular approach was indicated, were recruited and the modified submandibular incision was applied. The function of the facial nerve was followed up for six months using the Houseman-Brackman test. The esthetic result was assessed by two panels; consultant maxillofacial surgeons, and lay persons mainly concerned with the esthetics. The panel reviewed the cases through a power point presentation. A questionnaire customized to each panel’s expertise was then provided. Results: Surgeons grading intra-class correlation coefficient (ICC) showed that there was an excellent agreement in questions 1, 4, 5 and 7 (ICC=0.672, ICC=0.647, ICC=0.753 and ICC=0.679 respectively). The 5 different maxillofacial surgeons had excellent agreement on that the incision utilized accurately facilitated accessibility, good healing and pleasant esthetic outcome. Regarding lay persons grading, intra-class correlation coefficient (ICC) showed that there was an almost perfect inter-observer agreement on the success of the technique esthetically (ICC=0.826 and 0.838 respectively).Conclusion: the modified submandibular approach provided better aesthetic results and lower risk of facial nerve injury.

Submandibular approach for orotracheal intubation in Oral and Maxillofacial Surgery and Traumatology

Introduction: Submandibular tracheal intubation is a technique that can be applied in Oral and Maxillofacial Surgery and Traumatology, as well as other surgical specialties. Its main advantages are helping in the surgical manipulation of the middle facial skeleton and jaw and allowing the intraoperative control of dental occlusion. The technique is an alternative to elective tracheostomy. Objective and case report: The article presents the treatment of an adult patient, with sequelae of multiple fractures in the face due to a car accident, with endotracheal intubation using submandibular approach. Final considerations: In large surgical manipulations of the face, the submandibular approach for tracheal intubation allows a faster, facilitated anatomical access with a lower risk of damage to adjacent structures when compared to other pathways. It also guarantees excellent cervical mobility, the possibility of wide manipulation and the use of occlusion as a guide for surgical intervention.