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Year : 2021  |  Volume : 13  |  Issue : 6  |  Page : 1295-1299  

A comparative evaluation of transbuccal versus transoral approach for the management of mandibular angle fractures: A prospective, clinical, and radiographic study

1 Department of Oral and Maxillofacial Surgery, BM Gupta Hospital, New Delhi, India
2 Department of Dentistry, Shri Guru Ram Rai Institute of Medical and Health Sciences and Shri Mahant Indiresh Hospital, Dehradun, Uttarakhand, India
3 Department of Prosthodontics, Dayananda Sagar College of Dental Sciences, Bengaluru, Karnataka, India
4 Consultant Dental Surgeon, Kondapur, Rangareddy, Hyderabad, India
5 Department of Oral and Maxillofacial Surgery, Faculty of Dentistry, Aimst University, Kedah, Malaysia
6 Department of Oral and Maxillofacial Surgery, College of Dentistry, King Khalid University, Abha, Saudi Arabia
7 Ministry of Health, Riyadh, Kingdom of Saudi Arabia

Date of Submission26-Feb-2021
Date of Decision15-Mar-2021
Date of Acceptance26-Mar-2021
Date of Web Publication10-Nov-2021

Correspondence Address:
Bhavna Malik
Department of Dentistry, Shri Guru Ram Rai Institute of Medical and Health Sciences and Shri Mahant Indiresh Hospital, Dehradun, Uttarakhand
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jpbs.jpbs_112_21

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Introduction: In the facial bones, the angle of the mandible is the common site of fractures. Furthermore, it is the site with the highest number of complications after fracture and hence needs an efficient fixation. The right approach is still debatable for the angle fractures. In the light of these factors, we evaluated the transoral and the transbuccal approaches for the treatment of fractures at the angle of the mandible. Materials and Methods: Twenty patients were equally divided into two groups of transoral and transbuccal methods. The parameters such as ease of access, surgical time, occlusion, postsurgical infection, fracture gaps, scarring, and complications were noted, and the values that were compared were statistically analyzed. P < 0.05 was considered statistically significant. Results: No significant variations were seen in the variables such as ease of access, occlusion, postsurgical infection, and fracture gaps. Surgical time was significantly less for the transoral method. Negligible scarring was noted in the transbuccal method. Conclusion: Although both the methods were comparable, the transbuccal approach was more efficient for the mandibular angular fracture treatment.

Keywords: Mandibular angle fracture, transbuccal approach, transoral approach

How to cite this article:
Sehrawat K, Malik B, Vallabha H V, Vaishnavi AB, Pendyala SK, Ibrahim M, Binyahya FA. A comparative evaluation of transbuccal versus transoral approach for the management of mandibular angle fractures: A prospective, clinical, and radiographic study. J Pharm Bioall Sci 2021;13, Suppl S2:1295-9

How to cite this URL:
Sehrawat K, Malik B, Vallabha H V, Vaishnavi AB, Pendyala SK, Ibrahim M, Binyahya FA. A comparative evaluation of transbuccal versus transoral approach for the management of mandibular angle fractures: A prospective, clinical, and radiographic study. J Pharm Bioall Sci [serial online] 2021 [cited 2022 Aug 13];13, Suppl S2:1295-9. Available from:

   Introduction Top

In the facial bones, the angle of the mandible is the common site of fractures. Furthermore, it is the site with the highest number of complications after fracture and hence needs an efficient fixation.[1],[2] There are many approaches that have been proposed based on the socioeconomic conditions and the type of fracture.[3] The right approach is still debatable for the angle fractures.[4] Usually, the judgment for which approach to take up depends on the factors such as the visibility, fracture segments, displacement, and access. The judgment for which approach to be taken by the surgeon depends on the ease of procedure, patient desires, access to the fracture site, efficiency of the doctor, and equipment.[1] There are two most common approaches for the fracture management. They are intraoral and extraoral, with the submandibular and transbuccal approaches. Each method has its own advantages and disadvantages.[5] Although the ease of access is better with the extraoral method, the formation of scar and facial nerve damage are the main drawbacks. To overcome this, the intraoral/transoral approach was proposed. Although the esthetic and the nerve are preserved in this approach, higher infection chances are seen.[6] The transbuccal approach was proposed to overcome these disadvantages. In this method, the intraoral and small extraoral incisions are made [Table 1].[7] No scar is formed in this method; availability of thick cortical plates, lower infection, better access, less bending of the plate and fracture, and plate positioning in the neutral zone are the chief advantages.[7] For both transbuccal and transoral approaches, the miniplate fixation varies.[1] In the light of these factors, we evaluated the transoral and the transbuccal approaches done for the treatment of fractures at the angle of the mandible.
Table 1: Comparison of various parameters between the groups postsurgically

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   Materials and Methods Top

In our study, the total number of subjects was 20, who were divided into two equal groups of ten each for the transoral and transbuccal approaches. After obtaining the ethical clearance and informed consent, the subjects were selected between the ages of 15 and 60 years, with no other medical complications for the study. The radiographs were advised to check for the fracture displacement and the type. Blood tests were done. Preoperatively, antibiotics were given to the patients. A day early to the surgery, Erich's arch bars were placed for the occlusal stability. Postsurgery, the proper follow-up was done and instructions were given to the subjects. The clinical and the radiographic evaluation was done at 1, 3, and 6 months after surgery. The variables that were considered were as follows: the accessibility, which was given score as 1, 2, and 3 for good, fair, and poor respectively; postsurgical complications; and radiographic gap between the fractured segments. Postoperative occlusion was evaluated using the following scoring system: pretrauma (1), minor discrepancy (2), and major discrepancy (3). The results that were thus obtained from the study were statistically analyzed. P < 0.05 was considered statistically significant.

   Results Top

In our study, the mean age was 31.85 ± 9.85 years among the 20 subjects, with no significant age variation between the groups. There were no significant variations between the groups with the ease of surgical access, fracture gap, of postoperative occlusion, and postoperative infection at various time periods. A gradual decrease in the fracture gaps was noted radiographically, with the complete union of the segments by the end of 6 months were noted. The gap was less in the transbuccal group than the transoral group. The occlusal discrepancy was noted, but it was stable by the end of the 1st month. Infection was noted only during the 1st week of healing postsurgically. The time requires for the surgery was significantly less for the transoral approach than the transbuccal. Scar formation was seen only for the transbuccal group that healed and was not visible by the end of 1 month.

   Discussion Top

The angle of the mandible is the site in the facial skeleton with the highest rate of postsurgical complications as there has not yet been a consensus with the treatment modality, and the location of the angle is functionally complex.[1],[2] Due to the various factors (both the surgeon and patient related) that are to be considered for the angle fracture, various modalities for the treatment have been proposed.[2] Closed reduction is seldom considered for the angle management. For the open reduction, there are two methods: intraoral and extraoral approaches that are based on the principles of osseofixation.[2] Open reduction and internal fixation permits decent anatomical repositioning and speedy functional jaw movement.[1] With the advent of miniplates and screw systems, the treatment of angle fractures with rigid internal fixation is now the treatment opted by the surgeons.[2],[8]

The various methods such as intraoral transvestibular incision and extraoral submandibular/retromandibular or transbuccal approach can be done in the open reduction and internal fixation. These surgical approaches can be assessed through various parameters for their ease of use, time, accessibility, and skill required for the surgery. There have been studies done to compare the different approaches for the angle fractures.[2],[6],[7],[8],[9],[10],[11],[12],[13] The choice of treatment chosen depends on the anatomical location of the fracture line, type of fracture, dentition of the patient, and the amount of displacement of the fracture segments.[8],[9]

The extraoral approach has the advantage of access, whereas the scar and facial nerve damage are the drawbacks.[3],[8] For the intraoral approach, these disadvantages are overcome; however, in the adapting and positioning of the plate, difficulty is felt.[3],[8] After the consideration of the above, the transbuccal approach was adopted.

With the appearance of new procedures and development of miniplates, depicted by Champy, the surgery can be completed in an anatomically ideal position utilizing a transbuccal approach.[6] Nonetheless, transbuccal approach is as yet not generally satisfactory because of the hypothetical danger of harm to the involved nerve and an unesthetic scaring.[2],[6] For the transbuccal approach, the access to the fracture area is intraorally and the only a small percutaneous entry is made for the transbuccal trocar to allow the instrumentation. Although the extraoral approach provides a cleaner site for the operation, the transbuccal approach has shown fewer complications.[7],[12] Transbuccal approach is generally upheld in light of the fact that it brings about negligible or no scar formation and permits direct visibility and verification of proper occlusion during plate fixation.[14]

The instrumentation with the transbuccal trocar is technique sensitive that requires knowledge of its application by the doctor. No proof exists to show which technique is the best;[2] thus, the current examination was done to assess intraoral and transbuccal approaches.

In the current examination, 20 patients were enlisted with the occurrence of mandibular angle fractures. The patients with an average age of 31.08 ± 9.853 years were treated with intraoral or transbuccal methodology. Traffic accidents were the most widely recognized reasons, trailed by attacks.[2],[4]

In the current examination, intraoral and transbuccal methods were assessed. Surgical time is the period from incision and exposure of the surgical area till close. In our study, the time adopted for intraoral method (51.30 ± 5.334 min) was less contrasted with transbuccal (59.10 ± 2.514 min) method and was statistically significant (P < 0.05). The studies likewise have shown that more time is needed for the transbuccal method, for example, 64.9 min, when contrasted with transoral approach is 59.6 min in a Sugar et al.'s[2] study. This could be the objective behind why the intraoral methodology is done by the specialists.[4] The reduction of fracture was assessed utilizing OPG and PA through the set tracing points. When the reduction was assessed for various time periods, transbuccal approach showed better approximation than the transoral though not significant, with a mean of 0.50 mm and 0.25 mm, respectively. The explanation for such finding could be credited to better miniplate placement and the control of forces than the transoral approach.[4],[5] These results are in line with the research done by Kroon et al.[15] and Choi et al.,[16] where they noticed the gaps at the fracture site postsurgically. In intraoral method failures and complications were noticed due to small movements.[7],[10] These small movements if converts to large can cause malunions and other complications.

The motto in the treatment of fractures in the mandible is to reconstruct the original occlusion. We observed occlusion discrepancy among two subjects in the intraoral group, whereas transbuccal group had occlusal discrepancy in one patient at 1st postoperative week, though the difference in two approaches was insignificant. Transbuccal approach has direct visualization of occlusion. Intraoral approach requires more twisting of miniplate and screw placement. We observed in the 1st week, occlusal discrepancy, that was managed easily without any surgical intervention. By the end of the study period, all the subjects had satisfactory occlusions. In the trial done by Sugar et al., they proposed that many surgeons preferred the transbuccal approach.[2] We also observed similar results in our study; however, the method was technique sensitive with more surgical time needed. Even though the difference between the surgical access when comparing both the groups was found to be insignificant, surgical access was found to be better in favor of intraoral approach.

In the meta-analysis done by Al-Moraissi and Ellis,[17] they concluded that instead of using double miniplates, single miniplate was more successful for the angle fractures in the mandible, since fewer complications were seen. Similar observation was made in the present study as single miniplate was employed in both the methods. This was evident through the fracture reduction. We were able to achieve this with single miniplate fixation and reduced complications when compared with other studies using two miniplates.

On comparison with the observations of the present study, intraoral approach is a viable alternative for transbuccal approach, giving similar results. In the published literature, intraoral approach is superior when compared to extraoral, but in our study, we compared intraoral and transbuccal approaches.[7]

Despite the obvious advantages of transbuccal approach there is always a increase risk of infection. In our study, two patients in intraoral group and one patient in the transbuccal group had infection after surgery in the 1st postoperative week. This might be because of patient's poor oral hygiene or tooth in the line of fracture. However, infection was treated with antibiotics and wound healed uneventfully in both the groups, and the infection rate was statistically insignificant (P > 0.05).

The complications of transbuccal approach are dependent on many factors such as nature of wound, lacerations, and operator expertise. In the studies of Wan et al.[10] and Sugar et al.,[2] the transbuccal approach was not associated with the usual complications seen with other extraoral methods. These findings are in accordance with our study, where no unsightly scarring and no incidence of facial nerve palsy was seen fallowing the anatomical consideration when placing trocar.[14] In our subjects, scarring was minimal. A thorough knowledge of surgical region and anatomical variations with surgical experience limits the occurrence of these complications.

Intraoral approach provides an advantage of scarless surgery and more anatomic placement of plates according to Champy lines. Hence, in overall observation, the intraoral approach was convenient in parameters of surgical timing, extraoral scarring, and ease of operation. However, on the contrary, transbuccal approach showed better results over intraoral approach in parameters measuring occlusion discrepancy, surgical access, and fracture gap.

On comparison, both the techniques presented with similar findings and the difference was not statistically significant. The present study had limited number of patients, which compared only intraoral and transbuccal approaches with shorter duration of follow-up. Hence, longer duration of follow-up with larger sample size for confirmatory outcomes is suggested.

   Conclusion Top

The two methods are comparable. However, the transbuccal approach showed satisfactory reduction in the gap between the fracture segments postsurgically, adequate radiographic reduction in the fracture gap, minimal scar, and lesser complications. Facial nerve damage was not observed in our study. In the transbuccal approach, bending of the plate was least required that helped in positioning the plate at the neutral zone, whereas intraoral approach had an additional benefit in other parameters. It showed no external scarring. Intraoral approach showed ease of use and plating at external oblique ridge as suggested by Champy and facilitated placement of miniplate in the tension area of the angle of the mandible through intraoral incision. On comparison, both the techniques showed similar results and the difference was statistically not significant. Hence, our study results recommend the use of an intraoral approach over the transbuccal approach, considering reduced surgical time. A study with larger sample size is warranted to establish our observations.

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Conflicts of interest

There are no conflicts of interest.

   References Top

Khandeparker PV, Dhupar V, Khandeparker RV, Jain H, Savant K, Berwal V. Transbuccal versus transoral approach for management of mandibular angle fractures: A prospective, clinical and radiographic study. J Korean Assoc Oral Maxillofac Surg 2016;42:144-50.  Back to cited text no. 1
Sugar AW, Gibbons AJ, Patton DW, Silvester KC, Hodder SC, Gray M, et al. A randomised controlled trial comparing fixation of mandibular angle fractures with a single miniplate placed either transbuccally and intra-orally, or intra-orally alone. Int J Oral Maxillofac Surg 2009;38:241-5.  Back to cited text no. 2
Kale TP, Baliga SD, Ahuja N, Kotrashetti SM. A comparative study between transbuccal and extra-oral approaches in treatment of mandibular fractures. J Maxillofac Oral Surg 2010;9:9-12.  Back to cited text no. 3
Laverick S, Siddappa P, Wong H, Patel P, Jones DC. Intraoral external oblique ridge compared with transbuccal lateral cortical plate fixation for the treatment of fractures of the mandibular angle: Prospective randomised trial. Br J Oral Maxillofac Surg 2012;50:344-9.  Back to cited text no. 4
Sudhakar GV, Rajasekhar G, Dhanala S, Vura N, Ramisetty S. Comparison of management of mandibular angle fractures by three approaches. J Maxillofac Oral Surg 2015;14:979-85.  Back to cited text no. 5
Kumar S, Prabhakar V, Rao K, Brar R. A comparative review of treatment of 80 mandibular angle fracture fixation with miniplates using three different techniques. Indian J Otolaryngol Head Neck Surg 2011;63:190-2.  Back to cited text no. 6
Dierks EJ. Transoral approach to fractures of the mandible. Laryngoscope 1987;97:4-6.  Back to cited text no. 7
Devireddy SK, Kishore Kumar RV, Gali R, Kanubaddy SR, Dasari MR, Akheel M. Transoral versus extraoral approach for mandibular angle fractures: A comparative study. Indian J Plast Surg 2014;47:354-61.  Back to cited text no. 8
[PUBMED]  [Full text]  
Pattar P, Shetty S, Degala S. A prospective study on management of mandibular angle fracture. J Maxillofac Oral Surg 2014;13:592-8.  Back to cited text no. 9
Wan K, Williamson RA, Gebauer D, Hird K. Open reduction and internal fixation of mandibular angle fractures: Does the transbuccal technique produce fewer complications after treatment than the transoral technique? J Oral Maxillofac Surg 2012;70:2620-8.  Back to cited text no. 10
Gulses A, Kilic C, Sencimen M. Determination of a safety zone for transbuccal trocar placement: An anatomical study. Int J Oral Maxillofac Surg 2012;41:930-3.  Back to cited text no. 11
Khan A, Khitab U, Khan MT, Salam A. A comparative analysis of rigid and non rigid fixation in mandibular fractures: A prospective study. Pak Oral Dent J 2010;30:62-7.  Back to cited text no. 12
Shah A, Qureshi ZR. Post management complications of fracture mandible at the angle-an analysis. Pak Oral Dent J 2011;31:260-2.  Back to cited text no. 13
Fox AJ, Kellman RM. Mandibular angle fractures: Two-miniplate fixation and complications. Arch Facial Plast Surg 2003;5:464-9.  Back to cited text no. 14
Kroon FH, Mathisson M, Cordey JR, Rahn BA. The use of miniplates in mandibular fractures. An in vitro study. J Craniomaxillofac Surg 1991;19:199-204.  Back to cited text no. 15
Choi BH, Yoo JH, Kim KN, Kang HS. Stability testing of a two miniplate fixation technique for mandibular angle fractures. An in vitro study. J Craniomaxillofac Surg 1995;23:123-5.  Back to cited text no. 16
Al-Moraissi EA, Ellis E 3rd. What method for management of unilateral mandibular angle fractures has the lowest rate of postoperative complications? A systematic review and meta-analysis. J Oral Maxillofac Surg 2014;72:2197-211.  Back to cited text no. 17


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