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Dr. Asif NazirB.D.S., F.C.P.S. (Oral Surgery)
Senior Registrar, Oral & Maxillofacial Surgery Department
de’Montmorency College of Dentistry, Punjab Dental Hospital, Lahore.
Mandibular condylar fractures29.1 % of all
mandibular fractures.
Mandibular condylar fracturesMandibular condylar
fractures– a problem area– difficult to diagnose, difficult to approach & difficult to reduce and stabilize.
Selection of surgical approach• Level of fractureExisting lacerationOther associated fracturesSurgical exposure requiredCosmetic concerns of patientMethod of fixation
Surgical approachesTranscutaneous approaches
Pre-auricular (high condylar #)Retro-mandibular, trans-parotidSub-mandibular (low condylar #)Pre-auricular approach +/- retro-mandibularPre-auricular approach +/- sub-mandibularPeri-auricular, antero-parotid, trans-
masseterHemicoronal & coronal approachesEndoscopic approaches (Skin +/- oral)
Preauricular approachDingman’ approachFor condylar head & neck fracturesIncision consists of 2 limbs---one superior and
other inferior to tragusIncision is placed in pre-auricular crease
through skin s/c tissue to the temporal fascia
Preauricular approachThen undermining is
done towards the zygomatic arch
An oblique incision is made through the tissue near the root of zygoma to enter the the joint capsule and expose the condylar fracture.
Retromandibular approachFor condylar neck #s &
sub-condylar #s.Also known as ‘Hind’s
approach’ or ‘Post ramal approach’
Incision marking
Retromandibular approachSurgical anatomyFacial nerve—main
trunk and branches.
Retromandibular approachIncision is made 0.5cm
below the ear lobe & 1 cm behind the ramus of mandible
Retromandibular approachDissection through skin,
subcutaneous & deeper tissues & exposure of parotid capsule.
Retromandibular approachDissection through the
parotid gland.Exposure of posterior
border of ramus of mandible.
Retromandibular approach• Marginal mandibulr
nerve retracted postero-inferiorly.
• Buccal branch retracted superiorly.
• Masseter muscle is cut & retracted to expose posterior border of mandible.
Retromandibular approachFixation of sub-condylar
fracture with miniplate and monocortical screws.
Peri-auricular approachPre-auricle approach
with different modifi-cations
1. Retromandibular 2. Lasy ‘S’ modification 3. Rhytidectomy
Peri-auricuular approachPre-auricular approach
with lasy ‘S’ extansionA trans-masseteric
anteroparotid approach (TMAP).
Dissection in subdermal fat plane to gain access to the masseter adjacent to antero-inferior edge of parotid gland
Peri-auricuular approachTrans-messeteric dissec-
tion to expose the condylar fracture
Reduction of condylar fracture
Peri-auricuular approachFixation of condylar
fracture with two mini-plates and mono-cortical screws
Sub-mandibular approachAlso known as risdon approachIncision is made 2 cm below the angle of
mandibleSkin, s/c tissue, platysma and deep
cervical fascia are incised and dissection is performed superiorly to expose the sub condylar fractures
Intraoral (endoscopic)approach• Mandibular condylar fractures can be best
approached via intra-oral approach with the help of endoscope.
• Maa and Fang (1994)were the first to use endoscope for mandibular angle fracture.
• Jacobveiz used it for condylar fractures first time.
The best surgical approachLeast morbid
No permanent Facial palsyNo Frey’s syndromeNo Salivary fistula / SialocoeleLittle haemorrhage
Good cosmesis Excellent exposure & access