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ARTICLE IN PRESSBJOM-4153; No. of Pages 5

British Journal of Oral and Maxillofacial Surgery xxx (2013) xxx–xxx

Available online at www.sciencedirect.com

valuation of facial nerve following open reduction andnternal fixation of subcondylar fracture throughetromandibular transparotid approachngkila Bhutia a,∗, Lalit Kumar a, Anson Jose a, Ajoy Roychoudhury a, Anjan Trikha b

Department of Oral & Maxillofacial Surgery, All India Institute of Medical Sciences, New Delhi 110029, IndiaDepartment of Anaesthesia, All India Institute of Medical Sciences, New Delhi 110029, India

ccepted 1 December 2013

bstract

he objective of this study was to evaluate any damage to the facial nerve after a retromandibular transparotid approach for open reduction andnternal fixation (ORIF) of a subcondylar fracture. We studied 38 patients with 44 subcondylar fractures (3 bilateral and 38 unilateral) treatedy ORIF through a retromandibular transparotid approach. All patients were followed up for 6 months. Postoperative function of the facialerve was evaluated within 24 h of operation, and at 1, 3, and 12 weeks, and 6 months. Variables including type of fracture, degree of mouthpening, postoperative occlusion, lateral excursion of the mandible, and aesthetic outcome were also monitored. Nine of the 44 fracturesesulted in transient facial nerve palsy (20%). Branches of the facial nerve that were involved were the buccal (n = 7), marginal mandibularn = 2), and zygomatic (n = 1). In the group with lateral displacement, 2/15 showed signs of weakness, whereas when the fracture was mediallyisplaced or dislocated 7/23 showed signs of weakness. Of the 9 sites affected, 7 had resolved within 3 months, and the remaining 2 resolvedithin 6 months. The mean (range) time to recovery of function was 12 weeks (3–6 months). There was no case of permanent nerve palsy.

he retromandibular transparotid approach to ORIF does not permanently damage the branches of the facial nerve. Temporary palsy, thoughommon, resolves in 3–6 months. Postoperative occlusion, mouth opening, and lateral excursion of the mandible were within the referenceanges. We had no infections, or fractured plates, or hypertrophic or keloid scars.

2013 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.

al nerve

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eywords: Retromandibular transparotid approach; Condylar fracture; Faci

ntroduction

t has been reported that condylar fractures account for5–50% of all mandibular fractures.1,2 However, despite theigh incidence, their management is controversial. The mainonflict hinges on a choice between conservative and surgicalanagement.3,4 Those who prefer closed treatment question

he need for surgical management, because of the risks of

Please cite this article in press as: Bhutia O, et al. Evaluation of facial nefracture through retromandibular transparotid approach. Br J Oral Maxil

nfection, haemorrhage, an unsightly scar, and (most impor-antly) the possibility of injury to the branches of the facialerve. Supporters of open reduction claim that only it can

∗ Corresponding author. Tel.: +91 9313349564.E-mail address: dr ongkila@rediffmail.com (O. Bhutia).

afibtttd

266-4356/$ – see front matter © 2013 The British Association of Oral and Maxillofaciahttp://dx.doi.org/10.1016/j.bjoms.2013.12.002

; Morbidity

ive satisfactory results, and that it prevents long term effectsuch as shortening of the ramus, facial asymmetry, arthro-is of the temporomandibular joint, and impaired eating andpeaking.2,5

The risk of facial nerve palsy is one of the main argu-ents against surgical management.6,7 Several approaches

o the mandibular condyle have been described, whichnclude preauricular, submandibular, intraoral, rytidectomy,nd retromandibular.8,9 The retromandibular approach wasrst described by Hinds and Girroti in 196710 and modifiedy Koberg and Momma in 1978.11 It has an advantage over

rve following open reduction and internal fixation of subcondylarlofac Surg (2013), http://dx.doi.org/10.1016/j.bjoms.2013.12.002

he other methods in that it involves minimal working dis-ance from the incision to the fracture site and less morbidityo the facial nerve, which can be identified and retracted underirect vision. Other advantages include excellent exposure,

l Surgeons. Published by Elsevier Ltd. All rights reserved.

ARTICLE IN PRESSYBJOM-4153; No. of Pages 5

2 and Maxillofacial Surgery xxx (2013) xxx–xxx

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O. Bhutia et al. / British Journal of Oral

nd aesthetically pleasing results because of the less conspic-ous scar as it does not involve any supplemental incision andeduction is easy.12,13 Our aim was to document the dam-ge to the facial nerve when the retromandibular transparotidpproach was used for the treatment of subcondylar fractures.

atients and methods

his prospective clinical study included 38 patients with 44racture sites in the subcondylar region. Institutional ethicslearance was obtained before the study started. Only adultatients with fractures of the condylar neck and subcondyleith discrepancies in occlusion, those in whom pretraumaticcclusion could not be achieved by closed reduction, andhose who were not willing to have intermaxillary fixation,ere included. The function of the facial nerve preoperativelyas within the reference ranges in all cases.

urgical technique

atients were operated on by a senior surgeon. Access tohe fracture site was obtained through a retromandibularransparotid approach with an incision 0.5 cm below the earobe posterior to the posterior border of the ramus of the

andible, which extended inferiorly 3–3.5 cm up to the anglef the mandible. After the skin and subcutaneous incision hadeen incised a thin layer of platysma muscle was incised sohat the parotid capsule was visible. We used blunt dissec-ion parallel to the branches of the facial nerve, taking extrarecautions to avoid injury to any of them. The posteriororder of the ramus was then identified and the pterygo-assetric sling incised. The site of the fracture was exposed

ubperiosteally to expose the bone so that a suitable retrac-or could be used to expose the site as high as possible. Theeduction of a laterally-displaced fracture was easy. Lightlastics were placed in the arch bars and a broad instrumentlaced between the occlusal surfaces was used to distract theandible slightly caudally, while we simultaneously manip-

lated the condylar fragment into the fossa and reduced it.edially-displaced fractures required an assistant to push

own the ipsilateral molar region to give enough space toaise the medially-displaced fracture and to convert it into aaterally-displaced.fracture.

When the fragments were small and could not be moved, 2 mm screw was inserted and the head of the screw waseld by a heavy artery forceps to facilitate the fragment in 3-imensional reduction. Before the plate was fixed, we did aaxillomandibular fixation. The fracture was fixed with tita-

ium miniplates and screws using either 2 plates of a 2.0 mmon-locking adaptive system, or a single locking 2.0 mmlate. Once the fracture site had been fixed, the intermax-

Please cite this article in press as: Bhutia O, et al. Evaluation of facial nefracture through retromandibular transparotid approach. Br J Oral Maxil

llary fixation was released and occlusion was checked. Theound was closed in layers, extra care being taken while

uturing the parotid capsule to avoid a parotid fistula.Fc

ig. 1. Three-dimensional computed tomographic scan showing displace-ent of the subcondylar fracture.

ollow up

ostoperative follow up radiograph or computed tomographicCT) scan were taken to confirm reduction (Figs. 1 and 2).tandard assessment of motor response of facial nerveranches was made postoperatively as soon as the patienttarted to obey commands for voluntary facial muscle move-ents (within 24 h) (Table 1) and 1, 3, and 12 weeks, and 6onths postoperatively by one of the consultants. Ease of

ccess to the fracture site, occlusion, lateral excursion ofhe mandible, mouth opening, parotid fistulation, durationf operation, infection of plates, and aesthetic outcome ofound were also monitored.

esults

e evaluated 44 subcondylar fractures treated by ORIF using

rve following open reduction and internal fixation of subcondylarlofac Surg (2013), http://dx.doi.org/10.1016/j.bjoms.2013.12.002

ig. 2. Postoperative computed tomographic scan after fixation of the sub-ondylar fracture.

ARTICLE IN PRESSYBJOM-4153; No. of Pages 5

O. Bhutia et al. / British Journal of Oral and M

Table 1Tests used to assess the function of the facial nerve.

Movement thatpatients wereasked to make

Muscle Nerve

1 Frown andwrinkle forehead

Frontalis Temporal branch

2 Close eyes tightly Orbicularis oculi Zygomatic branch3 Puff up cheeks

and pucker lipsBuccinator,orbicularis oris

Buccal

4 Move lower lipdownwards and

Depressor angulioris, depressor

Marginalmandibular

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raffic crashes (n = 26, 68%) followed by fall (n = 6, 16%)nd assault (n = 6, 16%). Fifteen sites had displaced condylarragments with lateral overlap, in 23 there was dislocationith medial overlap, and 6 were not displaced. There was

ransient facial nerve palsy in the immediate postoperativeeriod (24 h) in 9 sites (20%). In the group with lateralisplacement (n = 15) some weakness was apparent in 2,hereas when the fracture was medially displaced or dis-

ocated (n = 23) there were signs of weakness in 7.Seven sites completely recovered within 3 months and the

emaining 2 within 6 months. The buccal nerve was involvedost often (n = 7) followed by the marginal mandibular nerve

Table 2). All the sites that took 6 months to recover involvedhe buccal nerve.

We also evaluated ease of access through exposure of frac-ure site, and 39/44 sites (89%) were straightforward and theperation took only about 30 min. The medially overlappednd dislocated fractures were difficult to locate and took morehan 30 min. The retromandibular transparotid approach pro-ided adequate access for reduction of the fracture. Clinicalnd radiographic evaluation showed good reduction in 38/44ites (86%), but in the remaining 6 there was some discrep-ncy. The sites with medial overlap required a great deal ofetraction and the operating time was prolonged. Immedi-te palsy of one or more branches of the facial nerve wasore likely to develop in sites in which there were signs of

islocation and medial overlap. The postoperative occlusion,outh opening, and lateral excursion of the mandible wereithin the reference ranges in all cases. No patient developed

nfection or fractured the plate, and there were no hyper-rophic scars or keloid. Three parotid fistulas responded toocal measures in 2–3 weeks postoperatively.

iscussion

he incidence of transient damage to branches of the facialerve has been reported to be between 12% and 48%Table 2) when the retromandibular transparotid approach

Please cite this article in press as: Bhutia O, et al. Evaluation of facial nefracture through retromandibular transparotid approach. Br J Oral Maxil

s used.5,7,8,13–16

Our incidence was 9/44 (20%). Such a high incidence maye attributed to the fact that access is between the branches

thV

axillofacial Surgery xxx (2013) xxx–xxx 3

f the parotid gland and retraction can lead to transienteuropraxia resulting in palsy. The sites that required extraetraction because of medial overlap and dislocated condy-ar fragments developed more transient nerve palsies thanhe ones with lateral overlap. When the fracture was laterallyisplaced or dislocated, only 2/15 showed signs of weakness,hereas when the fracture was medially displaced or dislo-

ated 7/23 showed signs of weakness. Neither in the studieseported elsewhere nor in our series was there any permanentamage (Table 3).

A preauricular incision can be used to avoid retractionnd is not in the vicinity of branches of the facial nerve.he low subcondylar fractures would be difficult to reduce

hrough an incision too high for such fractures, and it maye good only for high condylar fractures. The incidence ofacial nerve damage has been reported to be 3–48%17 with thereauricular approach. A submandibular approach can alsoe used for condylar fractures, but this has the disadvantagehat it is a large incision with limited access to the condy-ar fragment, and this might compromise the quality of theeduction and fixation. The submandibular approach has alsoeen reported to have an incidence of damage to the facialerve of 5–48%.18

Though injuries to the facial nerve using an intraoral routeave not to our knowledge been reported, comparisons withther extraoral approaches cannot be drawn because there isimited accessibility to the fracture site and a trochar and can-ula are used for fixation. A review of reports that comparedutcomes of traditional ORIF and endoscope-assisted ORIFf fractures of the mandibular condyle by Haug and Brandt19

howed a similar incidence of damage to the facial nerve,nd it also has a steep learning curve and requires expen-ive equipment. Wilson et al.20 described the transmassetericnteroparotid technique, which claims to reduce the occur-ence of salivary fistulation and damage to the facial nerve.he transparotid approach, however, requires blunt dissec-

ion of the parotid capsule and parenchyma of the parotid,hich increases the incidence of parotid fistulas and tem-orary damage to the facial nerve. Obese patients with fatheeks also pose problems. Trost et al.21,22 showed that theamage to the facial nerve can be minimised if a high cervicalransmasseteric anteroparotid approach is used.

The retromandibular transparotid approach gives directccess to the fractured area and is the only incision that islose to the fracture line. The facial nerve divides into the tem-orofacial branch (consisting of the temporal and zygomaticranches) and the cervicofacial branch (the buccal, marginalandibular, and cervical branches). The window between

he buccal and marginal mandibular branches is the area ofissection. The superior margin of incision is required to beetracted more for plating or for locating the medial overlap-ing condyle. This may the reason for the increased incidence

rve following open reduction and internal fixation of subcondylarlofac Surg (2013), http://dx.doi.org/10.1016/j.bjoms.2013.12.002

he studies of Ellis and Dean8 and Manisali et al.13 Similarigh incidences of buccal nerve palsy were also reported byesnaver et al.5 and Hyde et al.14 It is possible to reduce

ARTICLE IN PRESSYBJOM-4153; No. of Pages 5

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Table 2Reported incidences and sites of damage to the facial nerve.

First author and reference no. Year No. of patients No. of sites No. (%) withtransient facialnerve palsy

Branches affected

Ellis8 1993 Not stated 29 14 (48) Marginal mandibularEllis7 2000 83 83 16 (19) Marginal mandibular,

buccal, n = 5,periorbital, n = 2

Hyde14 2002 25 25 3 BuccalManisali13 2003 20 20 6 Marginal mandibular,

n = 6, buccal, n = 1Vesnaver5 2005 34 36 8 (22) Buccal, or zygomatic,

or bothDownie15 2009 50 51 7 (14) Buccal, n = 4,

zygomatic, n = 3Yang16 2012 42 48 8 (18) Buccal, or zygomatic,

or bothPresent study 38 44 9 (20) Buccal, n = 7,

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he incidence of buccal nerve palsy by dissecting the nervend protecting it from retraction with a suitable instrument.e made no attempt to visualise the nerve during dissec-

ion, but if we encountered it we retracted it away from theite. To minimise the amount of retraction needed, partic-larly in medially-displaced condylar fragments, a verticalubsigmoid osteotomy could be made so that the medialondyle could be located and fixated extracorporeally ashown by Ellis and Dean.8 The cut bone would be devoidf periosteal and muscular attachments and would act as aon-vascularised bone graft plated to the ramus.

Zygomatic nerve palsy was seen in one patient with a

Please cite this article in press as: Bhutia O, et al. Evaluation of facial nefracture through retromandibular transparotid approach. Br J Oral Maxil

edially dislocated condyle, and we encountered extremeifficulty during reduction of the fractured segments as theyequired more retraction of soft tissue over a longer period,

aAt

able 3eported duration of recovery after damage to the facial nerve.

irst author and reference no. Year Branches affected

llis8 1993 Marginal mandibular

llis7 2000 Marginal mandibular,buccal, n = 5,periorbital, n = 2

yde14 2002 Buccal

anisali13 2003 Marginal mandibular,n = 6, buccal, n = 1

esnaver5 2005 Buccal, or zygomatic,or both

ownie15 2009 Buccal, n = 4,zygomatic, n = 3

ang16 2012 Buccal, or zygomatic,or both

resent study Buccal, n = 7,marginal mandibular,n = 2, zygomatic, n = 1

marginal mandibular,n = 2, zygomatic, n = 1

hich resulted in retraction paralysis of this branch. Theacial nerve palsies that took longest to recover were asso-iated with medially displaced condylar fractures, whereonger operating time and more retraction of soft tissuesere required to locate and retrieve the fragments, and thisrobably resulted in traction neuropraxia of the facial nerve.

In neuropraxia functional recovery takes place within–12 weeks. However, during the postoperative period asedema increases the inflow of nutrients to the nerveecreases. This results in axonal death (axonotmesis) and ret-ograde degeneration. However, the endoneurium in this typef injury is intact and axons will regrow through the channels,

23

rve following open reduction and internal fixation of subcondylarlofac Surg (2013), http://dx.doi.org/10.1016/j.bjoms.2013.12.002

nd this results in late recovery of function (3–6 months). similar recovery pattern was seen in the present series. The

ransient palsy was probably the result of excessive retraction

Duration of recovery Time until fullrecovery

All within 16 weeks No case of totalparalysis

6 weeks, transientpalsy of all branches

All within 6 months

– 1 month2 within 1 month All within 3 months

6 within 4–8 weeks 1 mild weakness ofupper lip and lowereyelid at 13 months

– All within 5–15months

All within 2–4 weeks 1 month

7 within 3 months All within 6 months

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O. Bhutia et al. / British Journal of Oral

ather than neurotomesis. The mean duration of recovery was2 weeks (Table 3). The parotid fistulas were managed byocal dressings, having been the result of inadequate closuref the parotid capsule as also reported by Vesnaver et al.5

ater tight closure of the parotid capsule is recommended.The retromandibular transparotid approach is useful for

reating undisplaced and laterally displaced subcondylar frac-ures, and it has the advantages of direct access to the fractureite, an inconspicuous scar, no permanent damage to the facialerve, and easy open reduction and internal fixation. Thereay be a high incidence of transient nerve palsy but perma-

ent damage has not been reported to our knowledge. Whenhis approach is used for ORIF of subcondylar fractures carehould be taken to be gentle when retracting soft tissues.here is a role for preoperative and postoperative counsellingf patients who opt for this approach about temporary facialerve palsy.

ources of support in the form of grants

o sources of support in the form of grants.

ompeting interests

one declared.

thical approval

pproved by Institutional Ethical Committee.

eferences

1. Rowe NL, Killey HC, editors. Fractures of the facial skeleton. 2nd ed.Edinburgh: Churchill Livingstone; 1968. p. 80–92.

2. Silvennoinen U, Iizuka T, Lindquist C, et al. Different patterns of condylarfractures: an analysis of 382 patients in a 3-year period. J Oral MaxillofacSurg 1992;50:1032–7.

3. Takenoshita Y, Ishibashi H, Oka M. Comparison of functional recoveryafter nonsurgical and surgical treatment of condylar fractures. J Oral

Please cite this article in press as: Bhutia O, et al. Evaluation of facial nefracture through retromandibular transparotid approach. Br J Oral Maxil

Maxillofac Surg 1990;48:1191–5.4. Konstantinovic VS, Dimitrijevic B. Surgical versus conservative treat-

ment of unilateral condylar process fractures: clinical and radiographicevaluation of 80 patients. J Oral Maxillofac Surg 1992;50:349–52.

2

axillofacial Surgery xxx (2013) xxx–xxx 5

5. Vesnaver A, Gorjanc M, Eberlinc A, et al. The preauricular transparotidapproach for open reduction and internal fixation of condylar fractures.J Craniomaxillofac Surg 2005;33:169–79.

6. Chossegros C, Cheynet F, Blanc L, et al. Short retromandibular approachof subcondylar fractures – clinical and radiologic long term evaluation.Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:248–52.

7. Ellis III E, McFadden D, Simon P, et al. Surgical complications with opentreatment of mandibular condylar process fractures. J Oral MaxillofacSurg 2000;58:950–8.

8. Ellis III E, Dean J. Rigid fixation of mandibular condylar fractures. OralSurg Oral Med Oral Pathol 1993;76:6–15.

9. Ellis III E, Zide MF. Transfacial approaches to the mandible. In: Ellis IIIE, Zide MF, Manson PN, editors. Surgical approaches to facial skeleton.Baltimore: Lippincott Willams & Wilkins; 1995. p. 123–85.

0. Hinds E, Girotti W. Vertical subcondylar osteotomy: a reappraisal. J OralSurg 1967;24:164–70.

1. Koberg WR, Momma W. Treatment of fractures of the mandibular processby functional stable osteosynthesis using miniaturized dynamic compres-sion plates. Int J Oral Surg 1978;7:256–62.

2. Zide MF, Kent JN. Indication for open reduction of mandibular condylefractures. J Oral Maxillofac Surg 1983;41:89–98.

3. Manisali M, Amin M, Aghabeigi B, et al. Retromandibular approachto the mandibular condyle: a clinical and cadaveric study. Int J OralMaxillofac Surg 2003;32:253–6.

4. Hyde N, Manisali M, Aghabeigi B, et al. The role of open reductionand internal fixation in unilateral fractures of the mandibular condyles: aprospective study. Br J Oral Maxillofac Surg 2002;40:19–22.

5. Downie JJ, Devlin MF, Carton AT, et al. Prospective study of morbid-ity associated with open reduction and internal fixation of the fracturedcondyle by the transparotid approach. Br J Oral Maxillofac Surg2009;47:370–3.

6. Yang L, Patil PM. The retromandibular transparotid approach to mandibu-lar subcondylar fractures. Int J Oral Maxillofac Surg 2012;41:494–9.

7. Hammer B, Schier P, Prein J. Osteosynthesis of condylar neck fractures:a review of 30 patients. Br J Oral Maxillofac Surg 1997;35:288–91.

8. Widmark G, Bagenholm T, Kahnberg KE, et al. Open reduction ofsubcondylar fractures. A study of functional rehabilitation. Int J OralMaxillofac Surg 1996;25:107–11.

9. Haug RH, Brandt MT. Traditional versus endoscope-assisted open reduc-tion with rigid internal fixation (ORIF) of adult mandibular condylefractures: a review of the literature regarding current thoughts on man-agement. J Oral Maxillofac Surg 2004;62:1272–9.

0. Wilson AW, Ethunandan M, Brennan PA. Transmasseteric antero-parotidapproach for open reduction and internal fixation of condylar fractures.Br J Oral Maxillofac Surg 2005;43:57–60.

1. Trost O, Abu El-Naaj I, Trouilloud P, et al. High cervical transmasse-teric anteroparotid approach for open reduction and internal fixation ofcondylar fracture. J Oral Maxillofac Surg 2008;66:201–4. Erratum: JOral Maxillofac Surg 2008;66:607.

2. Trost O, Trouilloud P, Malka G. Open reduction and internal fixation of

rve following open reduction and internal fixation of subcondylarlofac Surg (2013), http://dx.doi.org/10.1016/j.bjoms.2013.12.002

low subcondylar fractures of mandible through high cervical transmasse-teric anteroparotid approach. J Oral Maxillofac Surg 2009;67:2446–51.

3. Selesnick SH, Patwardhan A. Acute facial paralysis: evaluation and earlymanagement. Am J Otolaryngol 1994;15:387–408.