|Year : 2016 | Volume
| Issue : 5 | Page : 175-178
Difficulties encountered in preauricular approach over retromandibular approach in condylar fracture
Perumal Jayavelu, R Riaz, AR Tariq Salam, B Saravanan, R Karthick
Department of Oral and Maxillofacial Surgery, Madha Dental College and Hospital, Chennai, Tamil Nadu, India
|Date of Submission||06-Apr-2016|
|Date of Decision||28-Apr-2016|
|Date of Acceptance||06-May-2016|
|Date of Web Publication||12-Oct-2016|
Dr. Perumal Jayavelu
Department of Oral and Maxillofacial Surgery, Madha Dental College and Hospital, Chennai, Tamil Nadu
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Fracture of mandible can be classified according to its anatomical location, in which condylar fracture is the most common one overall and is missed on clinical examination. Due to the unique geometry of the mandible and temporomandibular joint, without treatment the fractures can result in marked pain, dysfunction, and deformity. The condylar fracture may be further classified depending on the sides involved: unilateral/bilateral, depending on the height of fracture: intracapsular (within the head of condyle), extracapsular - head and neck (high condyle fracture), and subcondylar (low condyle fracture), and depending on displacement: nondisplaced, displaced (anteromedially, medially, and lateral), and dislocated. The clinical features include swelling and tenderness over the temporomandibular joint region, restricted mouth opening, and anterior open bite. A 34-year-old male patient reported to the Department of Oral and Maxillofacial Surgery at Madha Dental College and Hospital; suffered fall trauma resulting in bilateral condyle fracture, dentoalveolar fracture in mandible with restricted mouth opening, and anterior open bite.
Keywords: Approaches, condylar fracture, preauricular incision, retromandibular incision
|How to cite this article:|
Jayavelu P, Riaz R, Tariq Salam A R, Saravanan B, Karthick R. Difficulties encountered in preauricular approach over retromandibular approach in condylar fracture. J Pharm Bioall Sci 2016;8, Suppl S1:175-8
|How to cite this URL:|
Jayavelu P, Riaz R, Tariq Salam A R, Saravanan B, Karthick R. Difficulties encountered in preauricular approach over retromandibular approach in condylar fracture. J Pharm Bioall Sci [serial online] 2016 [cited 2019 May 23];8, Suppl S1:175-8. Available from: http://www.jpbsonline.org/text.asp?2016/8/5/175/191953
In mandibular fractures, the condylar fracture accounts for 25-50% of overall fractures. Condylar fractures are fractures of either the condyle or the most superior part of the condylar neck are confined to the intra capsular fracture and the fractures through the neck of the condyle, extra capsular fracture. The fractured segment can be nondisplaced, displaced (antero medially/ laterally) and dislocated from the disk. There are two principal therapeutic approaches to these fractures; functional and surgical. The surgical methods include open reduction and osteosynthesis with miniplates, wires or lag screws where as functional methods include intermaxillary wiring fixation. There are various approaches to the condyle as explained in the literatures. Each approach has it own advantage and disadvantage. This article reports a case of difficulties encountered in preauricular approach over retromandibular approach in condylar fracture.
| Case Report|| |
A 34-year-old male patient reported with a history of road traffic accident under the influence of alcohol. The chief complaint was restricted mouth opening, tenderness over temporomandibular joint, fractured upper central incisors, and intraoral swelling in submental region with extraoral laceration. The patient had no history of loss of consciousness, vomiting, seizure, convulsion, and ENT bleeding after trauma. On extraoral examination, laceration was seen on the lower lip and submental region and abrasion was seen on the tip of the nose and lateral border of the left eye and forehead. The extraocular muscle movements were normal and pupils were equally reacting to light which had a positive response. Complete examination of the body was done for any injuries and there were no positive findings.
On intraoral examination, the following were observed: Anterior open bite, restricted mouth opening (20 mm), tenderness while opening mouth over temporomandibular joint on both sides, condylar movement palpable on both sides, fractured maxillary incisor, swelling in the sublingual region, and root stumps in the posteriors. The patient was advised for computed tomography scan, orthopantomogram (OPG), and chest X-ray [Figure 1]. On radiological examination, OPG revealed extracapsular bilateral high condyle fracture with lateral displacement, dentoalveolar fracture in the lower anterior region, and maxillary central incisor. Under the guidance of the General Medicine Department, the chest X-ray revealed no abnormality.
The patient was informed and explained about the findings in the radiological examination and consequences if the fracture was not treated at the earliest. The patient was convinced for the full treatment of open reduction and internal fixation under general anesthesia and consent was taken. Before using the Risdon arch bar wiring, the patient was advised for blood investigation, the result was normal, and HIV and HbsAg were negative.
To treat dentoalveolar fracture and stabilization, Risdon arch bar wiring under local anesthesia is done. Routine preanesthetic evaluation was done and medication was administered. The patient was on nil per oral from 6 h before the surgery.
The right naso-endotracheal intubation was done and general anesthesia was administered. After extra- and intra-oral painting with povidone–iodine solution, preauricular incision was planned and surface marking was done using sterile toluidine blue on the right side. About 2% of xylocaine with adrenaline was infiltrated into the preauricular region, incision and dissection were made layer wise, and as exposing the fracture site, encountered vessels and nerve were identified and ligated. The fracture site was exposed, but there was difficulty in accessibility for reduction and fixation [Figure 2]. Hence, in addition, retromandibular approach was planned and executed [Figure 3]. Unlike the first approach, the fracture site was exposed and reduction was done. Considering the difficulties encountered for the right condyle reduction, retromandibular approach was planned for the left condylar fracture [Figure 4] and executed by the same procedure. After the reduction of bilateral condyle, the occlusion was checked and using tie wires, intermaxillary fixation was done.
Fixation was done using conventional mini plates and screws made of stainless steel on both sides, respectively:
- On the right condyle: 2 mm × 4 hole miniplate with gap and 2 mm × 2 hole miniplate with gap were placed and secured with 2 mm × 6 mm screws [Figure 5]
- On the left condyle: 2 mm × 4 hole miniplate with gap was palced and secured with 2 mm × 6 mm screws [Figure 6].
The occlusion was checked again and intermaxillary fixation wires were released. Meticulous wound closure was done in layers using 3'0' vicryl and 3'0' ethilon suture on the right preauricular incision and the right and left retromandibular incision. Beta-iodine was the ointment applied over the incised region and dressing was done with compression bandage on either side.
Extubation was done and recovery was uneventful. Postoperative instruction and medication were given and the patient was under observation for the next 3 days after surgery. Postoperative X-ray was advised after 2 days [Figure 7] and checked for occlusion.
| Results|| |
On postoperative examination; intraorally, the occlusion was maintained and extraorally, there was mild pain and difficulty during wrinkling of forehead, closure of eye, blowing of air, and whistling on the right side, which eventually recovered in 3 weeks; whereas the left side of the face was normal and radiological – there was a complete reduction, fixation, continuity of the bony contour was maintained, and condyle on both sides was in a proper position.
| Discussion|| |
There is controversy when it comes to treatment plan, either surgical (open reduction internal fixation) or functional (closed reduction) treatment. After many studies, it was given that fractures occurring in childhood can be treated with nonsurgical method to exploit the capability of the growing skeleton whereas in adult patients, surgical treatment depends on the type of fracture (displaced/dislocated). Depending on the height and position of the fractured segment, there are various approaches to the condylar process, but the only criteria for selection of the approach is done with the distance between the incision and the level of fracture.
The preauricular approach was initially given by Risdon (1934) and after that various modifications were proposed. The present modification widely followed is the modification made by Rowe (1972) and Al-Kayat and Bramley. In preauricular approach, the layers and structures encountered are skin, superficial fascia, deep fascia, parotid gland, facial nerve trunk and branches, superficial temporal vessels, auricular temporal nerve, transverse facial artery, periosteum, and condylar head and neck. The advantages includes visualization and alignment of high condylar and anteromedially displaced fractures whereas the disadvantages are scar formation, loss of sensation, Frey's syndrome, etc.
The retromandibular approach was initially given by Hinds and Girroti (1967) and modified by Koberg and Momma (1978). In retromandibular approach, the layers and structures encountered are skin, superficial fascia, buccal and marginal mandibular branch of facial nerve, parotid gland, masseter muscle, pterygomasseteric sling, retromandibular vein, external carotid artery, periosteum, posterior border of ramus, subcondyle and condylar neck, and the body of mandible. The advantages include exposure of entire ramus, distance from skin incision to the fractured site is less with minimal invasion, good access, and visualization. There is no purpose for transcutaneous trocar. The disadvantage would be its reduced accessibility to the medial displacement of fractured segment and damage to retromandibular vein.
There are limitations to each approach. In this particular case, though there was an adequate access and visibility to the fracture to retrieve, reduction and fixation were difficult through preauricular approach on the right side. Therefore, retromandibular approach was planned since the entire ramus can be approached easily for reduction and fixation of fracture. Combination of preauricular and retromandibular approaches can be done for easy accessibility, reduction, and fixation. On the other side, the condyle was approached and fixed through retromandibular approach alone. For fixation, transosseous wiring, stainless steel and titanium mini plates and screws were used, and the recent method would be the three-dimensional plates and screws. The result of mouth opening and mandibular movement in both the approaches is the same except clicking and mild pain are present in preauricular approach. This may be due to the direct exposure of temporomandibular joint.
| Conclusion|| |
Apart from several surgical approaches to laterally displaced condylar fracture, the reliable one for open reduction is retromandibular approach., There are several studies that have been done with the combination of Al-KayatBramley incision and retromandibular incision for easy reduction and fixation. Depending on the difficulties encountered during the surgery and postoperative complication of this particular case, retromandibular approach was the better approach when compared to preauricular approach and as a combination, it provides a wide access for the fixation of upper segment of the fracture. Hence, one can give preference to retromandibular approach over preauricular except in cases such as medial or anteromedially displaced or complete dislocation of the condylar segment.
We would like to acknowledge Dr. Mohana Priya. U, postgraduate student, for the contributions made to this article.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Handschel J, Rüggeberg T, Depprich R, Schwarz F, Meyer U, Kübler NR, et al.
Comparison of various approaches for the treatment of fractures of the mandibular condylar process. J Craniomaxillofac Surg 2012;40:E397-401.
De Riu G, Gamba U, Anghinoni M, Sesenna E. A comparison of open and closed treatment of condylar fractures: A change in philosophy. Int J Oral Maxillofac Surg 2001;30:384-9.
Ebenezer V, Ramalingam B. Comparison of approaches for the rigid fixation of sub-condylar fractures. J Maxillofac Oral Surg 2011;10:38-44.
Al-Kayat A, Bramley P. A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 1979;17:91-103.
Mohan AP, Jeevan Kumar KA, Venkatesh V, Pavan Kumar B, Patil K. Comparison of preauricular approach versus retromandibular approach in management of condylar fractures. J Maxillofac Oral Surg 2012;11:435-41.
Bhutia O, Kumar L, Jose A, Roychoudhury A, Trikha A. Evaluation of facial nerve following open reduction and internal fixation of subcondylar fracture through retromandibular transparotid approach. Br J Oral Maxillofac Surg 2014;52:236-40.
Narayanan V, Kannan R, Sreekumar K. Retromandibular approach for reduction and fixation of mandibular condylar fractures: A clinical experience. Int J Oral Maxillofac Surg 2009;38:835-9.
Becker AB. Condylar fractures; report of two cases, one treated by preauricular, the other by submandibular, open reduction. Oral Surg Oral Med Oral Pathol 1952;5:1282-6.
Devlin MF, Hislop WS, Carton AT. Open reduction and internal fixation of fractured mandibular condyles by a retromandibular approach: Surgical morbidity and informed consent. Br J Oral Maxillofac Surg 2002;40:23-5.
Ellis E 3rd
, McFadden D, Simon P, Throckmorton G. Surgical complications with open treatment of mandibular condylar process fractures. J Oral Maxillofac Surg 2000;58:950-8.
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]