Submandibular Approach Research Articles

A comparative study between transbuccal and extra-oral approaches in treatment of mandibular fractures

Mandibular angle fractures continue to be a common type of facial injury. The objectives in treatment are to effect rapid healing by anatomic reduction and fixation and to restore function and appearance with minimal disability and complications. Traditionally, when open techniques are utilised, the extra-oral approach is performed through a skin incision concealed in the submandibular crease. However, patients develop unsightly scars and there is a risk of injury to the marginal mandibular nerve. In comparison, the trans-oral approach, performed through an oral mucosal incision, results in minimal external scarring or injury to the marginal mandibular nerve and allows direct visualisation and confirmation of the desired occlusion during the placement of the miniplates. The basic aim of the study was to provide a treatment for the mandibular fractures which results in minimal scarring and fulfills all the functional needs of the patient. Patients coming to KLES PK Hospital and MRC with mandibular angle fractures requiring open reduction and internal fixation admitted under OMFS were taken for the study. The sample size of the study was 15. In one group, the patients were treated by extra-oral approach and the other group by transbuccal approach. In patients treated by transbuccal approach, special armamentarium consisting of trocar, cannula, and cheek retractor were used; and in both the groups, semirigid fixation was done using two miniplates with around a distance of 1cm. Total of 15 patients were treated, 10 with transbuccal approach and 5 with submandibular approach. It has been found that both techniques fulfill the functional requirements of the patients. Patients treated with submandibular approach developed obvious unsightly scars, whereas transbuccal approach results in minimal scarring. The results associated with clinical observations suggest that transbuccal approach is a superior and less time consuming approach than extraoral approach, but it requires special instruments, lots of skill by the operating surgeon in using the armamentarium, and a skilled assistant.

Submandibular Approach Through the Submandibular Gland Fascia for Treating Mandibular Fractures Without Identifying the Facial Nerve

: The submandibular, or Risdon, approach is the classic, reliable extraoral approach for treating mandibular fractures. Although the intraoral approach has been used recently for open reduction and internal fixation, in some cases, such as comminuted fractures or fractures in an atrophic mandible, the submandibular approach is still prerequisite. Damage to the marginal mandibular branch of the facial nerve is the only concern other than skin scarring. : To minimize the risk of neuropraxia, we prospectively assessed an approach for treating mandibular fractures at 24 surgical sites in 22 patients (17 men, 5 women; mean age, 54.3 years) using direct submandibular gland capsule fascial layer elevation that did not require identifying the facial nerve. : As complications, one patient (4.2%) had temporary facial weakness in the mandibular branch, but this resolved completely within 3 months. The postoperative clinical course was uneventful in the other patients with one minor fistula and minimal scarring. : In conclusion, submandibular gland capsular layer elevation without facial nerve identification is a safe and less time-consuming technique applying the submandibular approach for the treatment of mandibular fractures.

Oblique Osteotomy and Coronoidectomy in Extreme Prognathism of Apert Syndrome

We report a case of oblique osteotomy and coronoidectomy for correction of extreme prognathism in Apert syndrome.A 16-year-old girl presented with a prognathic mandible. A prototype model was formed using computed tomography. After a mock bilateral oblique osteotomy of the mandible, the distal segment did not overlap the proximal segment, and it caused bony impingement between the coronoid process and the subcondyle of the proximal segment. An oblique osteotomy of the mandible was done through a submandibular approach, and bilateral coronoidectomy followed. After surgery, mandibular parameters were reviewed. The mandibular plane-Frankfort horizontal (MP/FH) angle decreased from 44 to 11 degrees; and the mandibular plane-sella nasion (MP/SN) angle, from 52 to 17 degrees. The mandible rotated backward and caudally after the surgery.It is predictable that there will be a bony impingement between the coronoid process and the subcondyle of the proximal segment before surgery, and so an oblique osteotomy and coronoidectomy are planned ahead through an external approach.

Transparotid approach for tumor excision from the infratemporal space in temporomandibular joint reconstruction: a 3-year follow-up

Surgery for tumors extending into the infratemporal fossa requires adequate exposure to identify and protect vital structures. We present a patient who had, at some time in the past, been treated by condylar resection of the right temporomandibular joint (TMJ) because of a pigmented villonodular synovitis. The condyle had been replaced with a standard reconstruction plate that had eroded deep into the skull base. Prosthetic reconstruction of the TMJ was performed 1.5 years later after renewed bone tumor excision from the infratemporal space. The standard preauricular and submandibular approaches for implantation of a total TMJ prosthesis did not offer adequate access for tumor removal from the infratemporal fossa. The tumor was excised successfully through an additional transparotid approach.

Submandibular TCD approach detects post-bulb ICA stenosis in children with sickle cell anemia

Transcranial Doppler (TCD) ultrasound is a procedure commonly used to screen individuals with the major hemoglobin S diseases, Hb SS and Hb S-beta(0), for significant stenoses in the circle of Willis. Flow velocities above 200 cm/s have been shown to identify patients at elevated risk for cerebral infarction. Among TCD's limitations is the inability to insonate the distal extracranial, petrous, and cavernous internal carotid artery (ICA) through the standard transtemporal approach. We extended the submandibular approach to include infra-siphon portions of the ICA. Using the extended submandibular approach to evaluate these portions of the ICA, we identified stenotic lesions in 4 patients with Hb SS disease out of a population of 131 children with Hb SS. Three of the 4 patients had no history of overt stroke or stroke-like symptoms. Neuroimaging confirmed the stenotic lesions, and also revealed watershed infarction as well as discrete areas of silent infarction. All 4 children had neuropsychological impairment. The submandibular approach, when added to a standard transcranial Doppler examination, may increase the sensitivity of this technique to identify important potential sources of cerebral infarction.

Submandibular approach to the C2–3 disc level: microsurgical anatomy with clinical application

Approaching the C2-3 disc level is challenging because of its location behind the mandible and the vital neurovascular structures overlying the area. The purpose of this study was to illustrate in a stepwise fashion the microsurgical anatomy of the submandibular approach to the C2-3 disc. Ten adult formalin-fixed cadaveric specimens (20 sides) were studied. Particular attention was paid to the structures limiting the exposure. The authors measured the distance between the inferior border of the mandible and the marginal mandibular branch of the facial nerve running inferior to the mandible, the distance between the horizontal segment of the hypoglossal nerve and the hyoid bone, and the distance between the horizontal segment of the hypoglossal nerve and the mandible. They compared the location of the superior laryngeal nerve with regard to the submandibular and the standard Smith-Robinson approaches. A clinical case illustrating the usefulness of the surgical technique in this region is presented. The mean distance between the inferior border of the mandible and the lowest point of the marginal mandibular branch of the facial nerve was 6.7 +/- 1.69 mm. The hypoglossal nerve's mean distance above the hyoid bone was 8.4 +/- 1.78 mm and below the mandible was 19.6 +/- 6.39 mm. The internal branch of the superior laryngeal nerve, with respect to the cervical spine, always entered the thyrohyoid membrane just inferior to the C-3 vertebral body. The superior laryngeal nerve was found to be an impediment to approaching the C2-3 disc through the standard Smith-Robinson approach. The submandibular approach provides excellent exposure, with a perpendicular view of the C2-3 disc level. This approach is one of the options to be considered when dealing with high cervical pathologies.

関節突起部に生じた周辺性骨腫の1例

Osteoma is a benign tumor consisting of mature bone tissue. A solitary osteoma is classified as peripheral when it arises from the periosteum, central when it arises from the endosteum, and extraskeletal when it arises in soft tissue. Solitary osteomas occur mainly in the craniofacial bones. Peripheral osteomas arising in the condylar process of the mandible are rare. Here, we report a case of peripheral osteoma of the condylar process in a 62-year-old woman who complained of a cosmetic disturbance. The osteoma, 48 X 43 X 37 mm in a diameter, was surgically excised by a submandibular approach. The histopathological diagnosis was a compact osteoma. The patient remains free of recurrence after 1 year.

Clinical experience with osteosynthesis of subcondylar fractures of the mandible using TCP ® plates

To evaluate the clinical and radiological results obtained with a new kind of osteosynthesis device (Modus TCP) plates, Medartis, Basel, Switzerland), especially designed for low subcondylar fracture (LSCF) and high subcondylar fracture (HSCF) of the mandible in association with the high submandibular approach (HSMA). A prospective clinical and radiological study was carried out over a 41-month period. All adult patients suffering from a displaced LSCF or HSCF who consented to the surgical treatment were included in the study. All fractures were operated on using an HSMA and were stabilised using a 4- or 9-hole TCP((R)) plate. No intermaxillary fixation was used and a soft diet was started on the 1st postoperative day. Clinical examinations and control X-rays were carried out on the 10th postoperative day, in the 1st, the 3rd and, at least, in the 6th postoperative months. Sixty-four patients (12 females, 52 males - mean age: 28.3) with a total of 75 fractures (54 LSCF, 21 HSCF) were included in the study. Mean postoperative follow-up was 14 months. In the 6th postoperative month, all fractures were consolidated in 79% of the cases in an anatomical position. A secondary displacement of the fracture occurred in 6.6% of the cases. Plate fracture was not observed. Dental occlusion remained unchanged in 94% of the patients. The mandibular movements (mouth opening, protrusion, lateral movements on the unfractured and fractured side) had normal mean values (49.5, 10.4, 12.8, 12.1mm, respectively). These movements were symmetrical in 95% of the patients. No patient complained about articular pain or noise. No facial nerve palsy was noticed, not even a transiently one. All patients but one found the scars acceptable. TCP plates, in association with HSMA, were found to be an efficient osteosynthesis device for stabilising subcondylar fractures.

Tongue Transplantation: 10-Month Follow-up

Tongue Transplantation: 10-Month Follow-up

Submandibular approach for tracheal intubation in patients with panfacial fractures

The oral route for tracheal intubation can interfere with some maxillofacial surgical procedures. At the same time, the nasal route can be contraindicated or impossible. Tracheostomy is the usual solution in these circumstances, but it carries a high incidence of complications. We tested the submandibular route for tracheal intubation as an alternative to tracheostomy in such situations. The procedure was performed in 13 patients suffering from panfacial fractures associated with a fracture of skull base or a displaced nasal fracture, and in one patient with post-caustic burn scar affecting most of the face including the nose and requiring a full thickness skin flap surrounding the mouth. The technique was found easy and satisfactory for both the surgeon and the anaesthetist. It allowed uninterrupted surgical techniques and a secure airway. In six of the 13 patients, the submandibular tracheal tube was left in place for up to 44 h in the intensive care unit after the operation without complications or difficulties. Accidental dislodgement of the tube to the right main bronchus occurred in two patients while carrying out the procedure; it was rapidly detected and corrected. In another two patients, postoperative superficial infection occurred that responded well to local treatment. No other complications were encountered. Submandibular tracheal intubation is a simple and effective technique for upper airway management in some maxillofacial surgical patients when both oral and nasal tracheal intubations are not convenient.

Removal of the submandibular gland by a submental approach: A prospective, randomized, controlled study

There are few controlled studies on surgical approaches for excision of the submandibular gland (SMG). This study evaluated the benefits of a submental approach, compared with a conventional submandibular approach, for SMG resection. Twenty patients with benign SMG disorders, 12 with pleomorphic adenoma and eight with chronic sialadenitis with sialolithiasis, were resected using a submental (10) or submandibular (10) approach. The submental approach consisted of a horizontal incision on the submental skin and flap elevation to the gland, and the submandibular approach consisted of an incision along the skin crease overlying the SMG. Operation time, complications, hospital stay, cosmetic appearance and subjective satisfaction with the incision scar were compared between groups. The two groups were well matched in age, gender, marital status, and SMG disorders. Mean operation time, hospital stay and complication rates were comparable in the 2 groups. Mean patient satisfaction score was higher in the submental than in the submandibular group (8.8 vs. 5.4, P=.01), and the incision scar in the submental group was usually less visible. Compared with the submandibular approach, the submental approach can provide better cosmetic outcomes with no increases in operation time and complication rates.

Treatment of severe micrognathia accompanying obstructive sleep apnea hypopnea syndrome with rigid external distractor

To approach the treatment of severe micrognathia accompanying obstructive sleep apnea hypopnea syndrome (OSAHS) with rigid external distractor (RED) in children. Six cases patients (4 males, 2 females) aged between 1.5 and 14 years, were diagnosed as ankylosis of temporomandibular joint severe micrognathia, and OSAHS. Under the nasal intubation and general anesthesia, the surgical procedures were performed by submandibular approach and osteotomy was done in mandible body. Mini plate was fixed and connected to RED. The distraction procedure was carried out Patients' profile, posterior airway space, and the results of polysomnography were improved significantly. There were no complications. Four months after removing the RED, the new bone was well formed. RED technique has advantages of uncomplicated procedures, high quality of new bone formation, and accurate regulation in the treatment of micrognathia. It is especially suitable for the treatment of children with severe micrognathia whose mandibular body is too small to insert the internal distractor.

O.197 Arthroscopic TMJ findings following mandibular fractures

.By using an endoscopy assisted extraoral and transoral approach for open reduction of condylar mandible fractures with limited incisions, the risk of facial nerve damage and extensive visible scars can be reduced. The endoscopy-assisted treatment of 17 consecutive patients with fractures of the condyle was performed from April 1998 to December 1999. Of the 17 patients, 13 presented with additional mandibular fractures. Nine of the 17 patients were treated by a submandibular approach and eight by a transoral approach. Adequate anatomic reduction was achieved by the submandibular and transoral approach using an endoscopy-assisted technique. The transoral approach proved to be a reliable surgical approach for fractures of the mandibular condyle, even when dislocation with lateral override was present. In four patients, angulated drills and screwdrivers facilitated the transoral treatment of condylar fractures. Transbuccal stab incisions and the use of trochars were not needed in these four patients. The extraoral approach was indicated for severely dislocated fractures such as fractures with medial override or comminution.

Aneurysmal bone cyst of the coronoid process of the mandible

A rare case of aneurysmal bone cyst (ABC) located in the coronoid process of the mandible in a 12-year-old girl is presented. Treatment consisted of excision of the lesion through preauricular, submandibular and intraoral approach. An access osteotomy distal to second molar region was required to gain access to medial side of the coronoid process. To our knowledge, this is the third case of an aneurysmal bone cyst of the coronoid process of mandible. While examining a patient with a large expansile intrabony jaw cavity with thin peripheral bone, which is filled with blood without presence of bruit, thrills and pulse pressure, the diagnosis of aneurysmal bone cyst should be on top of the differential diagnosis list. Seventy-four to eighty-five percent of aneurysmal bone cysts of jaws occur in 10-20 years age group. Therefore, a pediatric dentist may be the first person to see such a lesion.

Intra-articular ramus ostectomy combined with costochondral grafting for the treatment of recurrent ankylosis of the mandible

Purpose This report seeks to demonstrate a technique for treating recurrent ankylosis of the mandible by creating a functional false joint at a level distal to the original joint. Patients and methods This is a retrospective study involving patients treated between 1999 and 2003. Under general anaesthesia the ramus was exposed via a submandibular approach and a block of bone was removed from it inferior to the sigmoid notch. Temporary intermaxillary fixation was applied. A costochondral graft was interposed between the resected ends of bone and secured with mini-plates. Postoperatively intermaxillary fixation was maintained for 3 days after which the jaw was actively mobilized. Results The technique was used in the treatment of six patients with recurrent ankylosis of the mandible ranging in age from 9 to 38 years. Follow-up was between 1 and 4 years. All the patients had a satisfactory interincisal opening ranging from 25 to 35 mm. Conclusion The technique does not require the exposure of the ankylosed joint proper but instead creates a false and functional joint at a lower level. It also permits lengthening and advancement of the mandible.

Granularzelltumor, ein seltener Tumor der Glandula submandibularis

Granular cell tumors are rare entities with manifestations in nearly all organ systems. Appearance in salivary glands is observed in singular cases. We report a 54 years old female patient with a painless submandibular tumor lesion. Using a submandibular approach the tumor was totally removed with the submandibular gland. Histologically a benign granular cell tumor was diagnosed. The immunohistological examination revealed positive for S-100 antigen and vimentin, negative for KL1 antigen. The clinical follow-up for about 3 years was without complications or tumor recidive. A differential diagnosis of a submandibular mass is the rare manifestation of a benign granular cell tumor. The neurogen origin can be proven immunohistologically by positive S-100 antigen detection. The complete surgical resection is the therapy of choice.

Jugular foramen schwannomas: a review of 17 cases

To analysis the clinical presentation, radiological findings, surgical techniques and outcomes of jugular foramen (JF) schwannomas. We reviewed our 10-year experience in the surgical treatment of 17 patients suffered from JF schwannomas in Hua Shan Hospital, Shanghai. A total of 8 males and 9 females with a mean age of 42 years underwent surgical procedures. A relative long period of 53-month symptomatic history was shown before surgery. The main clinical presentation are vertigo and hearing difficulty in 10 cases, atrophy of unilateral muscles of tongue in 9 cases, involvement of lower cranial nerve in 8 cases. The classification of tumors was type A (at cerebellopontine angle with minimal enlargement of the JF) in five cases, type B (JF with intracranial extension) in 3 cases, type C (extracranial tumors with JF extension) in 2 cases and type D (dumbbell-shaped with both intra-and extracranial components) in 7 cases. Far lateral approaches were used in 10 cases, retrosigmoid suboccipital approaches were used in 5 cases. Submandibular approaches were selected in other 2 cases. Gross total removal was achieved in 12 cases, and subtotal removal in 5 cases. Follow-up revealed marked improvement from preoperative symptoms in 9 cases and no additional deficits in 3 cases. 5 cases suffered from additional neurological deficits. There were two cases of temporary hoarseness and gradually improved within follow-up. Two patients suffered from swallowing problems as a new deficit. One patient had facial palsy. JF schwannomas can be surgically treated with relative good outcomes. Surgical approaches should be tailored according to the tumor extension.

Condylar Reconstruction by Vertical Sliding Ramus Osteotomy

A convenient method for condylar reconstruction through vertical ramus sliding osteotomy after condylectomy of the mandible is described. The method utilises the submandibular approach enabling a modification of the intracapsular temporomandibular joint arthroplasty and avoidance of excessive exposure of the temporomandibular joint capsule. This appears to prevent mandibular dysfunction postoperatively while maintaining the restored vertical dimension of the ramus.

Discussion

This elegant paper essentially shows that nerve growth factor is present in both the intimal lining and the outer adventitial lining of the femoral vein of rats, and as such, may encourage nerve growth down a vein such that it could be used as a conduit for nerve grafting procedures. The finding that nerve growth factor is present in the intima may mean that the vein does not need to be inverted to get the maximal benefit. It would be important to repeat this study in humans, and in fact this could be done fairly simply because it is often one of the facial veins that is used as a conduit for the inferior alveolar nerve when it is approached extraorally. Thus it would seem relatively straightforward to obtain an extra piece of vein whenever this is performed (or whenever any submandibular approach is used for any other procedure) and to subject this extra piece of vein to the same nerve growth factor studies. Human Research Committee approval should be obtainable for this kind of study. In fact, inversion of a human vein of the size of the facial vein (or the distal end of the saphenous vein) has proved very tedious and difficult in humans. We have managed to achieve it by inverting the vein over a 16-gauge catheter with a straight needle inserted through it and sutured around the periphery of the vein. The needle and catheter are then withdrawn, and as they do so, the vein is inverted. However, it would be nice to know that this is unnecessary.

Endoscopy-assisted open treatment of condylar fractures of the mandible: extraoral vs intraoral approach

Abstract.By using an endoscopy assisted extraoral and transoral approach for open reduction of condylar mandible fractures with limited incisions, the risk of facial nerve damage and extensive visible scars can be reduced. The endoscopy-assisted treatment of 17 consecutive patients with fractures of the condyle was performed from April 1998 to December 1999. Of the 17 patients, 13 presented with additional mandibular fractures. Nine of the 17 patients were treated by a submandibular approach and eight by a transoral approach. Adequate anatomic reduction was achieved by the submandibular and transoral approach using an endoscopy-assisted technique. The transoral approach proved to be a reliable surgical approach for fractures of the mandibular condyle, even when dislocation with lateral override was present. In four patients, angulated drills and screwdrivers facilitated the transoral treatment of condylar fractures. Transbuccal stab incisions and the use of trochars were not needed in these four patients. The extraoral approach was indicated for severely dislocated fractures such as fractures with medial override or comminution.