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surgical approaches to the mandibular condyle

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Page 1: surgical approaches to the mandibular condyle
Page 2: surgical approaches to the mandibular condyle

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.

Page 3: surgical approaches to the mandibular condyle

Mandibular condylar fractures29.1 % of all

mandibular fractures.

Page 4: surgical approaches to the mandibular condyle

Mandibular condylar fracturesMandibular condylar

fractures– a problem area– difficult to diagnose, difficult to approach & difficult to reduce and stabilize.

Page 5: surgical approaches to the mandibular condyle

Selection of surgical approach• Level of fractureExisting lacerationOther associated fracturesSurgical exposure requiredCosmetic concerns of patientMethod of fixation

Page 6: surgical approaches to the mandibular condyle

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)

Page 7: surgical approaches to the mandibular condyle

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

Page 8: surgical approaches to the mandibular condyle

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.

Page 9: surgical approaches to the mandibular condyle

Retromandibular approachFor condylar neck #s &

sub-condylar #s.Also known as ‘Hind’s

approach’ or ‘Post ramal approach’

Incision marking

Page 10: surgical approaches to the mandibular condyle

Retromandibular approachSurgical anatomyFacial nerve—main

trunk and branches.

Page 11: surgical approaches to the mandibular condyle

Retromandibular approachIncision is made 0.5cm

below the ear lobe & 1 cm behind the ramus of mandible

Page 12: surgical approaches to the mandibular condyle

Retromandibular approachDissection through skin,

subcutaneous & deeper tissues & exposure of parotid capsule.

Page 13: surgical approaches to the mandibular condyle

Retromandibular approachDissection through the

parotid gland.Exposure of posterior

border of ramus of mandible.

Page 14: surgical approaches to the mandibular condyle

Retromandibular approach• Marginal mandibulr

nerve retracted postero-inferiorly.

• Buccal branch retracted superiorly.

• Masseter muscle is cut & retracted to expose posterior border of mandible.

Page 15: surgical approaches to the mandibular condyle

Retromandibular approachFixation of sub-condylar

fracture with miniplate and monocortical screws.

Page 16: surgical approaches to the mandibular condyle

Peri-auricular approachPre-auricle approach

with different modifi-cations

1. Retromandibular 2. Lasy ‘S’ modification 3. Rhytidectomy

Page 17: surgical approaches to the mandibular condyle

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

Page 18: surgical approaches to the mandibular condyle

Peri-auricuular approachTrans-messeteric dissec-

tion to expose the condylar fracture

Reduction of condylar fracture

Page 19: surgical approaches to the mandibular condyle

Peri-auricuular approachFixation of condylar

fracture with two mini-plates and mono-cortical screws

Page 20: surgical approaches to the mandibular condyle

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

Page 21: surgical approaches to the mandibular condyle

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.

Page 22: surgical approaches to the mandibular condyle

The best surgical approachLeast morbid

No permanent Facial palsyNo Frey’s syndromeNo Salivary fistula / SialocoeleLittle haemorrhage

Good cosmesis Excellent exposure & access

Page 23: surgical approaches to the mandibular condyle