Submandibular Incision Research Articles

Does the surgical approach for treating mandibular condylar fractures affect the rate of seventh cranial nerve injuries? A systematic review and meta-analysis based on a new classification for surgical approaches

PurposeThe purpose of this study was to determine the rate of facial nerve injury (FNI) when performing (ORIF) of mandibular condylar fractures by different surgical approaches. Materials and methodsA systematic review and meta-analysis were performed that included several databases with specific keywords, a reference search, and a manual search for suitable articles. The inclusion criteria were all clinical trials, with the aim of assessing the rate of facial nerve injuries when (ORIF) of mandibular condylar fractures was performed using different surgical approaches. The main outcome variable was transient facial nerve injury (TFNI) and permanent facial nerve injury (PFNI) according to the fracture levels, namely: condylar head fractures (CHFs), condylar neck fractures (CNFs), and condylar base fractures (CBFs). For studies where there was no delineation between CNFs and CBFs, the fractures were defined as CNFs/CBFs. The dependent variables were the surgical approaches. ResultsA total of 3873 patients enrolled in 96 studies were included in this analysis. TFNI rates reported in the literature were as follows: A) For the transoral approach: a) for strictly intraoral 0.72% (1.3 in CNFs and 0% for CBFs); b) for the transbuccal trocar instrumentation 2.7% (4.2% in CNFs and 0% for CBFs); and c) for endoscopically assisted ORIF 4.2% (5% in CNFs, and 4% in CBFs). B) For low submandibular approach 15.3% (26.1% for CNFs, 11.8% for CBFs, and 13.7% for CNFs/CBFs). C) For the high submandibular/angular subparotid approach with masseter transection 0% in CBFs. D) For the high submandibular/angular transmassetric anteroparotid approach 0% (CNFs and CBFs). E) For the transparotid retromandibular approach a) with nerve facial preparation 14.4% (23.9% in CNFs, 11.8% in CBFs and 13.7% for CNFs/CBFs); b) without facial nerve preparation 19% (24.3% for CNFs and 10.5% for CBFs). F) For retromandibular transmassetric anteroparotid approach 3.4% in CNFs/CBFs. G) For retromandibular transmassetric anteroparotid approach with preauricular extension 2.3% for CNFs/CBFs. H) For preauricular approach a) deep subfascial dissection plane 0% in CHFs b) for subfascial approach using traditional preauricular incision 10% (8.5% in CHFs and 11.5% in CNFs). I) For retroauricular approach 3% for CHFs. PFNI rates reported in the literature were as follows: A) for low submandibular approach 2.2%, B) for retromandibular transparotid approach 1.4%; C) for preauricular approach 0.33%; D) for high submandibular approach 0.3%; E) for deep retroparotid approach 1.5%. ConclusionAccording to published data for CHFs, a retroauricular approach or deep subfascial preauricular approach was the safest to protect the facial nerve. For CNFs, a transmassetric anteroparotid approach with retromandibular and preauricular extension was the safest approach to decrease risk of FNI. For CBFs, high submandibular incisions with either transmassetric anteroparotid approach with retromandibular or transmassetric subparotid approach, followed by intraoral (with or without endoscopic/transbuccal trocar) were the safest approaches with respect to decreased risk of FNI.

Minimizing the Submandibular Incision in Endoscopic Subcondylar Fracture Repair.

Endoscope-assisted treatment of mandibular condylar fractures is an evolving surgical technique of this controversial subject. The approach is performed through an intraoral and additional submandibular incision. This study presents a technique for minimizing the length of the optional submandibular incision. Ten patients with displaced subcondylar fractures and malocclusion underwent endoscope-assisted open reduction and internal fixation (ORIF). A limited (<1 cm) submandibular incision (dissected under endoscopic guidance from within) was needed in eight patients to complement the intraoral incision and facilitate the reduction in the fractures. Satisfactory small scar could be obtained in all patients with neither wound complications nor facial nerve injuries. Our technique depends on dissection first then incision. Performing the external incision after complete intraoral dissection is safe for the facial nerve and minimizes scarring markedly. This very limited submandibular incision facilitates reduction in relatively difficult cases and enables clear visualization of posterior border of the mandible to confirm adequate fracture reduction.

Bilobed lipoma of submandibular region: an unusual presentation.

A 55-year old male patient presented to the Department of Oral and Maxillofacial Surgery with a swelling of the right submandibular region since four years [Table/Fig-1]. Swelling was painless asymptomatic and gradually increasing in size. On palpation swelling was firm with well-defined margins approximately (7x4 cm), swelling was mobile not fixed to overlying skin and no sign of inflammation. Patient was systemically normal. A tentative diagnosis was formed based on clinical examination which includes non-specific enlargement of right submadibular gland, lipoma, and lymphoma. [Table/Fig-1]: Clinical picture of lipoma in right submandibular region Contrast CT of right submandibular region showed a well circumscribed bilobed mass with mild extension into the parapharynegal space [Table/Fig-2] which was suggestive of benign lipomatous condition. A decision was made to surgically explore the lesion. [Table/Fig-2]: Contrast CT scan of the right submandibular region revealing the bilobed Tumour mass with mild extension into the parapharyngeal space After obtaining pre anaesthetic clearance, patient was admitted for excision of mass under GA [Table/Fig-3]. A submandibular incision was given to create access to soft tissue mass blunt dissection was done preserving marginal mandibular branch of facial nerve and a yellowish bilobed soft encapsulated mass was excised [Table/Fig-4,​,5].5]. Postoperative recovery was uneventful. Histological examination under 5 x magnifications showed sheets of mature adipocytes and lobules of adipose tissue separated from the surface epithelium by fibrous connective tissue stroma. The adipocytes were loosely arranged in large areas which showed presence of empty cytoplasm and small nuclei. Tumour cells were arranged in lobules. These lobules were separated from each other by fibrovascular connective tissue septae [Table/Fig-6]. [Table/Fig-3]: Outline of submandibular incision along with marking of inferior border of the mandible in order to save the marginal mandibular nerve during dissection [Table/Fig-4]: Intraoperative view of bilobed lesion separated from surrounding structures [Table/Fig-5]: Completely excised lesion along with parapharyngeal extension [Table/Fig-6]: Depicting the mature adipocytes and fat lobules separated by fibrous septae The presence of lipoma in the submandibuar region is extremely rare and it accounts for only 1-2% of all lipomas of the body. Angiolipomas and infiltrating lipomas are rarely found in the oral cavity [1] . There have been reports of deep intra muscular lipoma in the submandibular region by Adachi et al., [2] . Pusiol e t al., reported an oncocyticsialo lipoma of submandibular gland [3] . Diagnostic imaging techniques such as ultrasonograpghy, MRI and CT help to differentiate lipomas from other soft tissue lesion. And helps to identify the nature and exact location of lesion. However, the soft tissue characterization with ultrasonography is less specific than CT or MRI. When the mass is difficult to identify on ultrasonogram, CT or MRI is necessary. On CT scan it shows a high density from 83 to 143 Hounsfield units with well or poorly defined margins depending on the capsule [4].

A monolateral TMJ replacement under intraoral endoscopic assistance for jaw osteomielitis: a modified approach

Alloplastic replacement has become a valid treatment for TMJ endstage disease. The Alkayat and Bramley pre-auricular approach combined with the submandibular incision are the current surgical approaches for TMJ surgery. The present study shows a modified approach using intraoral endoscopic assistance. A female patient affected by jaw osteomielitis with condylar detachment was treated with total left TMJ alloplastic replacement combined with a right TMJ arthroplasty. No subamandibular incision was performed and, subsequently, the risks for permanent or temporary damage to the marginalis mandibulae nerve and surgical submandibular scar were avoided. Postoperative CT-Scan evidenced a good prosthesis position. No complications occurred after two years of follow-up.

Use of submandibular gland flap for repairing defects after tumor resection in the infratemporal region

ObjectiveTo investigate the application of submandibular gland flap with facial artery and vein pedicle, for repairing defects following tumor resection in the infratemporal region. Patients and methodsFifteen patients, including eight males and seven females ranging in age from 21 to 73 years, underwent surgical resection of tumors in the infratemporal region. Tumors were exposed using the submandibular incision approach and completely resected after pulling and rotating the mandible laterally. Mandibular osteotomy was performed for larger tumors or those that were not completely exposed. After tumor resection, the submandibular gland flap was used to fill up the residual defect following tumor resection. ResultsThe incisions healed well without exudation or infection (primary healing) postoperatively in all the patients. Long-term follow-up showed no tumor recurrence in all cases. Seven of the patients who underwent mandibular ramus osteotomy had numbness of the lower lip due to inferior alveolar nerve injury. No other complications were observed postoperatively. ConclusionThe submandibular gland flap with facial artery and vein pedicle is a reliable, effective, and easy approach for repairing the defects caused by tumor resection in the infratemporal region, and has great potential for application in the clinical setting.

Guinea Pig Model to Establish the Safety of Middle Ear Pellets

Objectives: Effective treatments for otitis media with effusion (OME) remain elusive as many patients have recurrence. Direct drug delivery to the middle ear has the potential to maximize efficacy, minimize side effects, and provide a sustained release treatment, which is particularly important in the treatment of biofilms. Polymer-based pellets are delivery vehicles for antibiotics and pellet placement in the middle ear is a potential future OME treatment. In vivo testing of these pellets in animal models is necessary prior to human application. Methods: Twenty-four adult guinea pigs were divided into 3 (n = 8) treatment groups: biological controls, surgical controls, polylactic glycolic acid (PLGA) pellets inserted in middle ear. The surgical approach involved submandibular incision, dissection, and following digastric up to the middle ear bulla. Perforating the bulla wall facilitated a 2.5-mm diameter pellet insertion. Auditory brainstem responses (ABRs) were recorded at 0, 1, 2, 4, and 16 weeks at 6 frequencies over 8 to 30 kHz. Analysis was performed using a paired t test with significance set at P &lt; .05 (Bonferroni correction). Results: Mean ABR thresholds across the 3 groups ranged between 42 and 49 dB SPL over 4 weeks. There were statistically significant threshold elevations between 4-10db SPL in the surgical control and pellet groups although these were not considered physiologically significant. Conclusions: Using a guinea pig model, PLGA pellet insertion into the middle ear caused ABR threshold elevation of only 4-10 dB SPL, supporting their use as a potential vehicle for middle ear drug delivery.

Accidental Displacement and Migration of an Endosseous Implant Into Submandibular Fossa

Accidental Displacement and Migration of an Endosseous Implant Into Submandibular Fossa

Combination of Autologous Protein-Rich Fibrin and Bone Graft: An Invaluable Option for Reconstruction of Segmental Mandibular Defects

Combination of Autologous Protein-Rich Fibrin and Bone Graft: An Invaluable Option for Reconstruction of Segmental Mandibular Defects

A Prospective Study on Management of Mandibular Angle Fracture.

To evaluate the results of management of mandibular angle fracture by open reduction and internal fixation using single non compression miniplate via transbuccal, intraoral or extraoral approaches. In this prospective study, 30 patients were randomly selected regardless of age, sex requiring open reduction and internal fixation of non comminuted angle fracture with/or without other associated fractures of the mandible. All the patients were operated under general anaesthesia following routine haematological, biochemical, general physical examination and routine radiographic examination. Patients were randomly distributed into 3 groups namely: (1) intraoral, (2) transbuccal, and (3) extraoral groups depending on the surgical approach used for open reduction and internal fixation of fracture of the angle of mandible. In the intraoral group (12 patients), angle fracture was approached through the intraoral vestibular incision similar to sagittal split incision. In the transbuccal group (8 patients), angle fracture was approached through the intraoral vestibular incision and transbuccal stab incision for screw fixation via trochar. In the extraoral group (10 patients), angle fracture was approached through the Risdon's submandibular incision. In all the patients, fractures were reduced with upper and lower Erich's arch bar fixation as means for IMF intraoperatively. In all the patients, fracture of the angle of the mandible was fixed with single non compression 2.5mm, 4 holed with gap stainless steel miniplate and 6/8mm monocortical screws. All patients were followed up for minimum of 6months to maximum of 24months. Complications were relatively minor such as paresthesia (on average 26.7% first post-operative day which was gradually improved and on average after 1month was 3.3%), mild to moderate occlusal discrepancies (on average 36.7%) which needed the post-operative intermaxillary fixation with elastics for 1-2weeks, infection (20% on average) was mild to moderate which was managed with antibiotic therapy and/or incision and drainage except in one case, plate removal was done under general anaesthesia (extraoral group) because of recurrent infection. Post-operative pain was mild to moderate (mean VAS score pre operative-6.17, post-operative 1week-1.63) which was managed with analgesics. Mouth opening was recorded in all patients which was on average 20.98mm preoperatively which improved to 40.57mm after 1month. The use of a single non compression miniplate for fractures of the angle of the mandible is a simple, reliable technique with relatively rare major complications and few minor complications irrespective of the surgical approach used for the open reduction.

Predicting the course of the marginal mandibular nerve: an evaluation of surgical landmarks

The inferior branch of the marginal mandibular nerve (IMB) is at risk of injury during surgical neck dissections due to its variability. Often surgeons rely on a two‐finger breadth, and/or 2cm distance below the inferior border of the mandible for submandibular incision placement (Witt, 2006). The purpose was to evaluate the accuracy of the landmarks and to define other fixed landmarks to avoid IMB injury. In ten Thiel embalmed specimens, six independent raters palpated/pinned the inferior border of the mandible and a line two‐finger breadths below. Each pinhead was digitized (Microscribe®) and a superficial musculoaponeurotic (SMAS) flap was raised using a Ridson approach. The IMB was identified and digitized from the parotid gland to the depressor anguli oris/labii inferioris. The digitized data were modeled (Autodesk Maya®) and distances between the IMB and landmarks quantified. The distance from the IMB to the inferior border of the mandible varied from 2.5–11.5mm (7.5±2.9) suggesting that in some cases the 2cm landmark may be risky. The two‐finger breadth line to the IMB was 18.9–38.2mm (30.6±7.2) indicating adequate clearance for the nerve. Other landmarks have been documented. To avoid injury of the IMB during surgical neck dissections, easily measurable and reliable bony landmarks should be identified which can accurately predict the course and distribution of the nerve.

Surgical Approach to the Pterygopalatine Fossa—Comparison Between Anterior Approach and Lateral Approach

The anterior and the lateral approach for resecting an invading tumor in the pterygopalatine fossa region were compared. An anterior approach was applied for resecting a malignancy that originated from the maxillary tuberosity, upper hard plate, and maxillary sinus, and a lateral approach was applied for resecting a malignancy that originated from the upper gingiva and buccal mucosa. The anterior approach was capable of exposing the whole maxilla, although it was difficult to achieve such exposure by the lateral approach. However, the submandibular incision technique used in the Dingman approach was useful for upper neck dissection as well as for exposure of the artery and vein to anastomose them for reconstruction. The anterior approach should be useful for resection of the pterygopalatine fossa concomitant with total maxillectomy. On the other hand, the lateral approach might have an advantage in terms of its cosmetic effects.

The Extratemporal Facial Nerve and Its Branches: Analysis of 42 Hemifacial Dissections in Fresh Persian (Iranian) Cadavers

The facial nerve controls facial muscles and expressions. Variability in branching patterns of the nerve creates variability in facial animation, which is evident in facial plastic surgery both between patients and ethnic groups and between sides of the face. Identifying relationships between the main trunk of the facial nerve and its network of branches to soft tissues/bony fixed points contributes to safer aesthetic and reconstructive techniques. The authors evaluate facial nerve branches in Persian (Iranian) cadavers, propose classification of the extratemporal nerve, determine topography of the nerve using fixed facial points, and define a new fixed point. Twenty-one cadavers were dissected, for a total of 42 hemifaces. Bicoronal and preauricular to submandibular incisions were made to deglove the face. Coded data were analyzed using a statistical program. The average of various quantitative and qualitative data points was analyzed. Averaged quantitative variables were compared between groups. The primary fixed index to specify the main trunk of the facial nerve was a point on a line from the upper edge of the tragus to the tip of the mastoid. The study confirmed the variable branching pattern of the extratemporal facial nerve. Temporal branches on the zygomatic arch numbered 1 to 3. Distance from the nearest branch to the tragus was 20.62 ± 3.84 mm on the right and 21.33 ± 3.10 mm on the left. The variability in distribution may explain different facial expressions among ethnic groups. Research using cadavers may improve facial surgery procedures and clarify variability in the facial nerve branching patterns among different ethnic groups.

Granular cell ameloblastoma showing desmoplasia

Our case of ameloblastoma had a surprisingly long 25 year history, with abnormally large dimensions, a multilocular diffuse-mixed radiographic picture, and was histopathologically diagnosed as granular cell ameloblastoma with desmoplasia. To the best of our knowledge, this is the first ameloblastoma ever reported, that has shown combined features of granular cells, desmoplasia, ameloblastic follicles, plexiform, and acanthomatous patterns. The nature of granular cells in this type of tumor and the significance of their presence have also been reviewed. From the studies on aameloblastomas to date, it seems that the old belief that granular cell ameblastoma is the most aggressive variant of ameloblastoma is a myth, and in all probability, granular cells are just a transitional or matured phase in the life cycle of ameloblastomas, starting with normal stellate reticulum-like cells, leading to a production of granules and finally leading to degeneration and formation of cystic areas.

Technique of Making Holes and Passing Wires in Subcondylar Fractures

The aim of this study was to describe the precise method for making holes and passing wires in a subcondylar fracture. The subcondylar fracture sites were accessed by making a submandibular incision. At the preauricular area, an 18-gauge 1.5 needle (inner diameter, 1.05 mm) was put from the skin to the distal end of the proximal fragment. Then a no. 1 Kirschner wire (diameter, 0.9 mm) was then inserted through the needle; it passed through the proximal fragment and was retrieved. Thus, a small hole approximately 1 mm was made on the proximal segment. A 27-gauge suture wire (diameter, 0.38 mm) was passed through the needle and the hole on the proximal segment. The tip of the wire was pulled using a loop made of a paper clip at the medial side of the proximal fragment. Another hole was made at the distal (major) segment with the same method. The tip of the wire, which traversed through the proximal fragment, was put into the hole on the distal segment, making a figure-of-8 pattern. The wire was tightened, and the fracture site was immobilized.We believe that this method of making holes and passing wires using a needle and K-wire might be a simple and quick alternative technique for treating subcondylar fractures.

An unusually placed ectopic mandibular third molar: case report and discussion of management

AbstractWe present the case of an ectopic mandibular third molar at the lower border of the ramus of the mandible associated with a dentigerous cyst. An extraoral surgical approach using a submandibular incision was used to extract the tooth. We discuss other reports of a similar nature and detail our management of this condition and the rationale for an extraoral surgical approach.

Preauricular Transcondylar Approach for Basal Cell Adenoma of Parotid Coexist With Ganglion Cyst of the Ipsilateral Temporomandibular Joint

The concurrence of 2 independent neoplasias in the ipsilateral parotid and the temporomandibular joint (TMJ) region was infrequently reported. In this article, we present a unique case characterized by the coexistence of a rare salivary gland tumor, basal cell adenoma, of the parotid gland with a ganglion cyst in the ipsilateral TMJ region. A special surgical procedure was also presented here using a modified preauricular incision and transcondylar approach for extracapsular dissection of both lesions. Previously published literature are about the traditional treatment of benign parotid tumors using partial or total parotidectomy with the preservation of facial nerve mainly via an S-shaped submandibular incision and approach. Here, for the first time, a special surgical method using preauricular transcondylar approach for this unique case of synchronous occurrence of parotid tumor and TMJ cyst is reported.

Bilayer Reconstruction for Parry-Romberg Syndrome

When using a free flap to reconstruct a facial deformity caused by Romberg's disease, it is important to prevent the flap from sagging after the operation. We report a new method of reconstructive surgery using a free subscapular adipofascial flap to prevent this problem. Three female patients (ages 27, 28, and 34 years) with Parry-Romberg syndrome underwent microsurgical free scapular flap transfer for buccal defects. This operation requires making a gingivobuccal sulcus incision and forming a pocket for buccal fat reconstruction by dissecting over the periosteum of the maxillary bone. Preauricular and submandibular incisions are made to create a subcutaneous pocket for flap transfer. After the subscapular flap is elevated, we use its angiogram to observe its vascular pattern. The flap is separated to preserve the main blood vessels horizontal lower branches. The subcutaneous adipose tissue layer uses the horizontal branch, and the buccal fat pad layer the lower branch. After the operations, the adipofascial flaps were in good condition and without postoperative complications. A half year after the first operation, revisional surgery was performed for one patient. No cases showed no sagging of the cheek, and in every case the overall appearance of the buccal region improved significantly. Reconstruction of the buccal fat pad and subcutaneous adipose tissue using a free bilobed adipofascial flap nourished by the circumflex scapular artery, returned the adiposal tissue to its normal position, assuring more natural facial contours.

Different Surgical Approaches for Multiple Fractured Atrophic Mandibles

Atrophic edentulous mandible fractures in geriatric patients have low incidence but present several biological and biomechanical peculiarities that produce a nonunion rate of around 20%. Surgical extraoral approaches for internal fixation of these fractures can be transcervical or by one or two submandibular incisions. Two patients sustaining multiple fractures in atrophic edentulous mandible are presented: the first patient was 72-years-old, treated by two submandibular incisions, and the second was 81-years-old, treated by transcervical approach. We discuss the advantages and drawbacks of each approach and their indications according to the Luhr et al (1996) atrophy index.

気管の偏位を伴った巨大な顎下部類表皮囊胞の1例

We report the case of a giant epidermoid cyst of the submandibular region with tracheal deviation. The patient was a 24-year-old man with an asymmetric face caused by enlargement of the left side of the neck. Magnetic resonance imaging （MRI） showed a high-signal intensity, clear-bordered mass （greatest dimension, 210 × 160 mm） on T2-weighted images, displacing the trachea. Needle aspiration yielded a bean-curd, refuseshaped, keratinized substance and yellowish white viscous fluid. A dermoid cyst or epidermoid cyst was suspected. A cystectomy was performed via a submandibular incision under general anesthesia . Although the cyst had a thick capsule surrounded by mild adhesions, it was extirpated after aspiration and reduction of the contents of the cyst because its major axis was 230 mm, making en bloc removal difficult. The cystic wall was composed of keratinizing stratified squamous epithelium, and did not include a dermal appendage. The pathological diagnosis was an epidermoid cyst. The postoperative course has been good, and respiratory discomfort has also improved. About 1 year postoperatively, the face is symmetric, and there has been no evidence of recurrence.

Perforator-Based Anterolateral Thigh Adipofascial or Dermal Fat Flaps for Facial Contour Augmentation

We describe our experience with perforator-based anterolateral thigh (ALT) flaps for facial contour augmentations in a standardized two-step procedure. In a series of eight consecutive patients (two men, six women) suffering from contour deformities due to different reasons (scleroderma: three, Parry-Romberg syndrome: three, trauma: one, tumor: one), soft tissue augmentations were performed via a preauricular approach. Flaps were harvested from the ALT as perforator-based dermofat (two) or adipofascial flaps (six) with only a small sheet of fascia and a minimal cuff of muscle around the perforators. All flaps were anastomosed to the superficial temporal vessels. For refinement of the primary result, excess volume was removed and minor contour irregularities were smoothed out after 6 months. Despite the small-vessel caliber, anastomoses caused no problems, and all flaps healed well. Because defects were located close to the temporal vessels, the length of the perforator pedicle was always sufficient. Facial contour could further be improved after secondary reshaping of the healed flaps. This led to nearly perfect long-term facial symmetry in all cases. The ALT proved to be a reliable donor site, providing enough well-vascularized fatty tissue for facial contour augmentation in normal-weight patients. No submandibular incision is necessary if the perforators are anastomosed to the superficial temporal vessels. The preauricular incision gives an excellent view to the operating field.