Li H, Zhang G, Cui J, Liu W, Dilxat D, Liu l. A Modified Preauricular Approach For Treating Intracapsular Condylar Fractures To Prevent Facial Nerve Injury: The Supratemporalis Approach. J oral maxillofac surg. 2016 may;74(5):1013-22.

PRESENTED BY – DR. SHEETAL KAPSE

GUIDED BY – DR. RAJASEKHAR G.

AUTHORS

1. Li H - Resident, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.

2. Zhang G - Associate Professor, Department of Stomatology, Xinqiao Hospital, Third Military Medical University, Chongqing, China.

3. Cui J - Attending Staff, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.

4. Liu W - Resident, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.

5. Dilxat D - Resident, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China.

6. Liu l - Professor, Department of Oral and Maxillofacial Surgery, West China Hospital of Stomatology, Sichuan University, Chengdu, China. Drs Li and Zhang are co-first authors.

CONTENTS

IntroductionPurpose & Aim Materials and methodsResults & DiscussionCross referencesConclusionPros and Cons of studyReferences

Introduction

Condylar fracture is one of the most common fractures in the mandibular region, with an incidence ranging from 29 to 52%.

However, condylar fractures are more difficult to handle than other mandibular fractures because -

1) There are many complex anatomic structures around the condyle in such a small area;

2) Some serious complications, such as facial deformity and TMJ ankylosis, can occur;

3) When condylar fractures occur in children, they can cause mandibular growth disturbance and even severe mandibular deficiencies.

Introduction

Of these 3 types, the intracapsular condylar fracture is most common, accounting for 65% of cases.

More desirable is - not only for anatomic reduction of fragments, but also for the added insurance of an intact TMJ disc. It also can promote prompt functional exercise.

Classic preauricular approach was described by Rowe and others. advantages, including excellent access to the joint, simple manipulation of fracture segments, and invisible scar formation.

He D, Yang C, Chen M, et al: Intracapsular condylar fracture of the mandible: Our classification and open treatment experience. J Oral Maxillofac Surg 67:1672, 2009

Rowe N: Surgery of the temporomandibular joint. Proc R Soc Med 65:383, 1972

Introduction

However, the facial nerve remains at risk of injury with the preauricular approach, which cannot be ignored.

According to well documented reports, the incidence of facial nerve paresis ranges from 1 to 32% after this surgery.

Hall MB, Brown RW, Lebowitz MS: Facial nerve injury during surgery of the temporomandibular joint: A comparison of two dissection techniques. J Oral Maxillofac Surg 43:20, 1985

Dolwick MF, Kretzschmar DP: Morbidity associated with the preauricular and perimeatal approaches to the temporomandibular joint. J Oral Maxillofac Surg 40:699, 1982

Purpose & Aim

Purpose : to prevent facial nerve injury using the supratemporalis approach in the treatment of intracapsular condylar fractures.

The authors hypothesized they could decrease facial nerve injury in patients with intracapsular condylar fractures through a supratemporalis approach.

Aim : to compare the 2 surgical approachesfor treating intracapsular condylar fractures with regard to prognoses and complications and validate the effectiveness of the supratemporalis approach presented in this study to prevent facial nerve injury.

Materials and methods

In this prospective cohort study, the population consisted of patients diagnosed with intracapsular condylar fractures who received surgical treatment from July 2005 to May 2014.

Inclusion criteria: • Clinical and imaging diagnoses of intracapsular condylar fractures, • Have no previous surgical treatment, • Consent to the surgical treatment, • Have any of the following fracture types:1. Displaced fracture in which the ramus stump was dislocated laterally out of the

glenoid fossa;2. A fracture with reduction of mandibular ramus height;3. Fracture that caused serious occlusion disorders or an extreme limited

maximum interincisal distance that could not be solved by closed treatment;4. A fracture that was displaced into the middle cranial fossa.

Materials and methods

Patients in the experimental group were treated with the supratemporalis approach, and patients in the control group were treated with the traditional preauricular surgical technique.

Exclusion criteria: 1. Undisplaced or only slightly displaced fracture2. Refused surgical treatment3. Traumatic scar at the temporal and preauricular regions that would affect

placement of the planned incision4. Previous facial nerve injury.

TECHNIQUE FOR CONTROL GROUP

n = 40 & 48 sides

The skin flap consisted of skin, subcutaneous tissue, and superficial temporalis fascia.

TECHNIQUE FOR EXPERIMENTAL GROUP

n = 44 & 64 sides

TECHNIQUE FOR EXPERIMENTAL GROUP

Results

84 patients (112 sides) with intracapsular condylar fractures were treated surgically (56men, 28women;mean age, 29.85 yr; range, 4 to 70 yr);

44 patients (64 sides)were treated with the supratemporalis approach and 40patients (48 sides)were treated with the traditional preauricular approach.

Facial contours and functions recovered well postoperatively in all 84patients.

Results

Discussion

It should be noted that reductions were ideal and fixations were reliable in the 2 groups.

All 84 patients showed substantial improvement in esthetic appearance and function.

No patients in either group developed postoperative auriculotemporal syndrome or wound infection.

The supratemporalis approach did not increase the frequency of other complications.

Cross references

Drake MT, Clarke BL, Khosla S. Bisphosphonates: Mechanism of Action and Role in Clinical Practice. Mayo Clin Proc. 2008 September ; 83(9): 1032–1045.

Osteoporosis

Glucocorticoid-Induced and Transplant-Associated osteoporosis

Immobility-Induced Osteoporosis

Other Causes of Acute Bone Loss

Paget Disease of Bone

Malignancy - Breast Cancer, Prostate Cancer, Multiple Myeloma

Osteonecrosis of the Jaw

Atrial Fibrillation

Over suppression of Bone Turnover

Hypocalcemia

Acute Inflammatory Response

Severe Musculoskeletal Pain

Clinical Uses Adverse effects

Presented 12 cases with pts age 10.7-17.2 Most of them were affected with osteoporosis. Pamidronate or olpandronate was continued for 2-8 years. Normal Linear growth, catch-up growth at puberty, bone

biopsy reports, normal calcium balance, radiographs Concluded the bisphosphonates as beneficial treatment

option specially in whom other therapies are ineffective.

Babakurban ST, Cakmak O, Kendir S, et al: Temporal branch of the facial nerve and its relationship to fascial layers. Arch Facial Plast Surg 12:16, 2010

Dissection of the middle third of the coronal strip in a freshcadaver specimen. The superficial layer of the deep temporal fascia (S-DTF)continues across the zygomatic arch (ZA) as the parotideomassetericafascia. The temporoparietal fascia (TPF) continues as the superficialmusculoaponeurotic system (SMAS). IFP indicates intermediate fat pad;MM, masseter muscle; PG, parotid gland; SFP, superficial fat pad.

The temporal branch of the facial nerve emerged from the parotid gland below the zygomatic arch (Figures 6 and 10) and traversed inside the temporoparietal fascia over the zygomatic arch following the Pitanguay line.

The numbers of temporal branch twigs passing over the zygomatic arch were 1 (14.3%), 2 (57.1%), 3 (14.3%), or 4 (14.3%) in the specimens

Anatomic variations of the temporal branch of the facial nerve make it vulnerable to injury during surgical dissection in the temporal region.

The nerve occasionally lies within the superficial temporal fat pad.

The modification of the skin incision was carried through the deep temporalis fascia with the fat tissue, exposing the temporal muscle.

Pros Cons Good sample size

Prospective study

Long term follow up

No additional complication

Overcomes anatomic variations

Knowledge of dissection planes

Pros and Cons of study

Conclusion

The supratemporalis approach provides excellent exposure of the surgical field with minimal complications.

Compared with the traditional approach, the supratemporalis approach effectively prevents injury to the facial nerve.

Therefore, the authors suggest this surgical method as a routine approach to treat intracapsular condylar fractures.

References

1. He D, Yang C, Chen M, et al: Intracapsular condylar fracture of the mandible: Our classification and open treatment experience. J Oral Maxillofac Surg 67:1672, 2009

2. Rowe N: Surgery of the temporomandibular joint. Proc R Soc Med 65:383, 1972

3. Dolwick MF, Kretzschmar DP: Morbidity associated with the preauricular and perimeatal approaches to the temporomandibular joint. J Oral Maxillofac Surg 40:699, 1982

4. Hall MB, Brown RW, Lebowitz MS: Facial nerve injury during surgery of the temporomandibular joint: A comparison of two dissection techniques. J Oral Maxillofac Surg 43:20, 1985

5. Babakurban ST, Cakmak O, Kendir S, et al: Temporal branch of the facial nerve and its relationship to fascial layers. Arch Facial Plast Surg 12:16, 2010

6. Weinberg S, Kryshtalskyj B: Facial nerve function following temporomandibular joint surgery using the preauricular approach. J Oral Maxillofac Surg 50:1048, 1992

7. A.W. Wilson,,M. Ethunandan, P.A. Brennan. Transmasseteric antero-parotid approach for open reduction and internal fixation of condylar fractures. British Journal of Oral and Maxillofacial Surgery (2005) 43, 57—60.