SURGICAL

APPROACHES
TO THE FACIAL
SKELETON :
mandible and TMJ Made by
Ragavi PG II
 CONTENTS
• Introduction
• Basic principles of incision placement
• Transoral approaches to the facial skeleton
• Approaches to the alveolus
• Approaches to mandibular third molar
• Mandibular vestibular approach
• Others
• Transfacial approaches to the mandible
• Submandibular approach
• Retromandibular approach
• Periangular approach
• Rhytidectomy approach
• Others
INTRODUCTION
• Maximum success in skeletal surgery depends on adequate access
to and exposure of the skeleton.
• In orthopaedic surgery, the basic rule is to select the most direct
approach possible to the underlying bone.
• Therefore, incisions are usually placed very near the area of
interest while major nerves and blood vessels are retracted.
• This involves little regard for esthetics.
• Surgery of the facial skeleton, however, differs from general
orthopaedic surgery in several important ways.
 Preservation of
Aesthetics vital structures

Surgical
approach

Access and Anatomic factors

visualization (e.g. - wrinkle lines)
Principles of incision placement
Place Incisions
Perpendicular to
the Surface of
Non-hair-
bearing Skin

Place Incisions
Use as Long Avoid Important
in the Lines of
an Incision as Neurovascular
Minimal
Necessary Structures
Tension

Seek other
favourable sites
for incision
placement.
LANGERS LINES
Oriented perpendicular to direction
of underlying muscle fibres

Crease lines present on skin as a

functional adaptation

Conspicuous in ageing face

Incision placed along these lines

result in less conspicuous scar
TRANSORAL APPROACHES
Approach to the alveolus

Crevicular incision

Envelope flap Triangular flap Trapezoidal flap

SEMILUNAR INCISION

• Indicated in apical
surgeries
• Avoid trauma to free
gingiva
• Disadvantage is limited
access
CRESTAL INCISION

• Indicated in edentulous
ridge
• wound edges can be readily
approximated due to the
thickness of the mucosa in
this region
• produces less swelling and
inflammation. 
Approaches to third molar
• Envelope flap ( two cornered flaps )
• Short or long
• Triangular flaps ( three cornered flaps )
• L shaped flap
• Bayonet shaped flap
• Ward’s incision
• Modified ward’s incision
• Comma shaped incision
• S shaped incision
• Szmyd flap
• Modified szmyd flap
• Berwick‟s tongue flap
 Mandibular vestibular approach
• allows relatively safe access to the entire facial surface of the mandibular
skeleton, from the condyle to the symphysis.

ADVANTAGE DISADVANTAGE
-
• Ability to constantly assess the • Limited access in some regions,
dental occlusion during surgery. such as the lower border of the
• Relatively rapid and simple mandible at the angle and parts
• Gives a hidden intraoral scar. of the ramus.
• Complications are few but
include mental nerve damage
and lip malposition
Structures to be protected

• Mental nerve
• The only neurovascular structure
of body region
• Terminal br of inferior alveolar
nerve, sensory in origin, three
branches
• When they enter lower lip, they
are seen superficial beneath the
mucosa
• Facial vessels
• Usually not encountered but seen
during dissection through
periosteum near antegonial notch
• Artery crosses mandible at anterior
border of masseter where it is
covered by skin and platysma,
pulsation noted.
• Vein is located posterior and
superficial to artery.
• At inferior border, artery and vein
are separated by bone only from
periosteum
• Mentalis muscle
• Other muscles of facial expression
are readily reattached with soft
tissue closure, but mentalis muscle
should be properly repositioned, if
not will droop and produce lifeless,
sagging appearance.
• Origin of mentalis muscle
determines the depth of labial
sulcus
• Innervated by marginal
mandibular br of facial nerve
• Buccal fat pad
• Fat extends inferiorly to just
above the occlusal plane
• Hence, incision made through
buccinator muscle superior to
occlusal plane will cause entry
into the fat pad.
 Anteriorly-a curvilinear
incision is given leaving
10-15 mm of mucosa
attached to gingiva

Once through the mucosa,

the underlying mentalis
muscles fibers are sharply
incised in an oblique
approach to the mandible
• incision -made more superiorly in the canine and premolar region
to avoid severing branches of the mental nerve.

• scalpel - oriented perpendicular to the bone when incising above

the mental foramen to prevent incision of this nerve.
In the body and posterior portion of the
mandible, the incision is placed 3 to 5
mm inferior to the mucogingival
junction.

The posterior extent of the incision is

made over the external oblique ridge,
traversing mucosa, submucosa,
buccinator muscle, buccopharyngeal
fascia, and periosteum
The mentalis muscle is stripped from the
mandible in a subperiosteal plane, up to the
inferior border of the symphysis.
Controlled dissection and
reflection of the mental
neurovascular bundle
facilitates retraction of the
soft tissues away from the
mandible. The periosteum
is totally freed
circumferentially around
the mental foramen.
Retracting the facial tissues
laterally will gently tense
the mental nerve. Using a
scalpel, the surgeon then
incises the stretched
periosteum longitudinally,
paralleling the nerve fibres
in two or three location.
Posterior dissection
• Buccinator attachments stripped : allowing
the muscle to retract upward, minimizing the
chance of herniation of the buccal fat pad.

• Temporalis muscle fibers : stripped by

inserting the sharp end of a periosteal elevator
between the fibres and the bone as high on
the coronoid process as possible, and
stripping downward

• Masseter is stripped from the lateral surface

of the ramus sweeping the periosteal elevator
superoinferiorly
Closure

• Closure is begun in the posterior areas grabbing mucosa, submucosa, the

cut edge of the facial muscles, and the periosteum, if possible.

• Mentalis muscle is firmly reattached to its origin to prevent ptosis of the

lip and chin. A minimum of three deep resorbable sutures are placed in the
mentalis muscle to reapproximate the cut edges
 Modifications of intra-oral incisions
• Intra-oral subcondylar
osteotomy : incision is made
down to bone along the
anterior edge of the ramus,
distal to the last molar tooth
the knife is turned laterally and
the cut continued to the
bottom of the buccal sulcus,
the incision in the periosteum
may be extended

REF : SUBCONDYLAR OSTEOTOMY OF THE MANDIBLE AND THE INTRAORAL APPROACH RONALD P. WINSTANLEY, F.D.S., L.R.C.P., M.R.C.S. Hope
Hospital, Salford
• Intraoral sagittal osteotomy :
Incision extending over
anterior border of ramus
extending downwards through
the middle of retromolar pad
to a point 5mm behind second
or third molar, incision then
winds laterally and forward to a
point distal to first molar
• Anterior subapical
osteotomies : The incision is
started about 1 cm behind the
planned vertical osteotomy
and is carried forward about 4
to 5 mm below the attached
tissue until reaching the cuspid,
at which time it can be dropped
down and carried to the
midline to connect with an
opposing incision
• Posterior subapical
osteotomies : An incision is
started 3 to 4 mm laterally to
the attached gingiva,
beginning at the anterior
border of the vertical ramus.
This incision is made down into
the bone and is carried forward
to the cuspid.
 TRANSBUCCAL APPROACH
• Extends the versatility of transoral approaches.
• In addition to the transoral exposure the soft tissues
overlying the posterior mandible are pierced from
externally.
• special instrumentation- transbuccal handle with
cannula.
• Through the cannula, drilling and screw insertion
becomes possible at a right angle to the lateral
mandibular surface.
• INDICATIONS
• Fixation of fractures of the mandibular angle
• Sagittal split osteotomy sites
 ENDOSCOPIC APPROACH
• Takagi first used this technique in 1918
• Standard intraoral incision can be used
• Condylar fracture can be approached through intra or extra oral approach
• A subperiosteal dissection is performed for creation of optical cavity.
• The 30, 4mm diameter endoscope, xenon light source is used.
• The endoscope allows for easy visualization of condyle and inferior border of the
mandible
• The scope can be used to reconfirm the planned procedure.
• Appropriate documentation can be recorded.
• The procedure can be completed with less morbidity with greater margin of
safety(avoiding technical error).
Transfacial approaches
 SUBMENTAL APPROACH
• The submental approach is used to expose
anterior mandibular body and symphysis.
• Usually they can be approached intraorally.
However, depending on the difficulty or
severity of the fracture, and/or the presence of
a laceration suitable, an extraoral approach via
the submental route may be indicated.
• An advantage to this approach is that the
surgeon can easily inspect the lingual surface
of the mandible to assure optimal reduction of
the fracture in this region.
• There are no major neurovascular structures in
the submental area.
• Variations in incision:
A) Following curvature of
anterior mandible
B) Hidden in submental skin
crease
• Carry the incision through the
skin and subcutaneous tissues
to the platysma muscle.
The platysma muscle must be
divided.
• There may be a natural
separation of the muscle in the
midline region. Additionally the
platysma muscle can become
very thin in this region.
• Dissection is carried out to the
inferior border of the mandible.
The periosteum is incised
sharply and the flap is elevated
to expose the anterior surface
of the symphysis.
• The wound is closed in layers to
realign the anatomic structures
and to eliminate dead space.
• The periosteum and platysma
muscle should be closed in
different layers.
• The submental incision can be
extended laterally to
encompass both the right and
left mandible by degloving the
entire lateral surface of the
mandible in the same way as in
the submandibular approach.
• This may be necessary in
complex fractures such as
comminuted, atrophic, and
severe bilateral fractures.
 Submandibular approach
• The submandibular approach is one of the most
useful approaches to the mandibular ramus
and posterior body region, and is occasionally
referred to as the Risdon approach.

• used for obtaining access to a number of

mandibular osteotomies, angle/body fractures,
and also for condylar fractures and TMJ
ankylosis.
STRUCTURES TO PROTECT

• Marginal mandibular nerve

• Facial vessels

• Submandibular gland
MARGINAL MANDIBULAR BRANCH OF
FACIAL NERVE
DINGMAN AND GRABB ZIARAH AND ATKINSON
• 100 facial halves • 76 facial halves
• In 19% 1cm below the inferior • 53% found below the inferior
mandible mandible
• Anterior to facial artery, all • 6% continued to stay inferiorly
dissections showed above the after crossing facial artery
inferior border
INCISION SHOULD BE MADE ATLEAST 1.5CM BELOW THE INFERIOR
BORDER OF THE MANDIBLE
DINGMAN AND GRABB
• 21% single branch
• 67% two branches
• 9% three branches
• 3% four branches
1 BRANCH 2 BRANCHES
FACIAL VESSELS
• Facial artery grooves or passes
through the submandibular gland as
it rounds the lower border of the
mandible.
• Visible on the external surface of the
mandible around the anterior border
of masseter muscle
• It is tortuous and anterior to facial
vein
• Facial vein runs across the surface of
the submandibular gland to end in
the internal jugular vein
 Preparation and draping -the corner of
the mouth and lower lip should be
exposed within the surgical field
anteriorly and the ear, or at least the ear
lobe, posteriorly

The initial incision of 1.5 to 2 cm inferior

to mandible is carried through skin and
subcutaneous tissues to the level of the
platysma muscle

Retraction of the skin edges reveals the

underlying platysma muscle, the fibers of
which run superoinferiorly..
Division of the fibers can be performed
sharply with knife, or bluntly with the
tips of a haemostat

Superficial layer of deep cervical fascia

exposed. The submandibular salivary
gland can also be visualized through
the fascia, which helps form its capsule

Dissection through superficial layer

upto pterygomasseteric muscular sling-
Submandibular glad retracted inferiorly
Facial vessels isolated and ligated
 pterygomasseteric sling is
sharply incised with a scalpel
along the inferior border,

The entire lateral surface of the

mandibular ramus (including the
coronoid process) and body can be
exposed to the level of the TMJ
capsule, taking care to avoid
perforating into the oral cavity
along the retromolar area
Closure

• The masseter and medial pterygoid

muscles are sutured together with
interrupted resorbable sutures.
• The platysma muscle may be
closed with a running resorbable
suture.
• Subcutaneous resorbable sutures
followed by skin sutures are placed.
 EXTENDED SUBMANDIBULAR APPROACHES TO THE
INFERIOR BORDER OF THE MANDIBLE

• For increased ipsilateral exposure, the

submandibular incision can be extended
posteriorly toward the mastoid region,
and anteriorly in an arcing manner toward
the submental region.
• Once the incision leaves the direction of
the resting skin tension lines however, the
resultant scar will be more obvious.
• To eliminate some of the undesirable
scarring that may accompany the change
in direction of the incision toward the
submental area, one can step the anterior
portion of the incision.
• Surgical splitting of the lower
lip is another maneuver used
occasionally in combination
with incisions in the
submandibular area to increase
the exposure of one side of the
mandible.
• Each method uses the principle
of breaking up the incision line
to minimize scar contracture
during healing.
• For complete bilateral exposure
of the mandible, one can use an
"apron" flap with or without lip
splitting.
• Bilateral submandibular incisions
are extended into the neck and
then connected.
• The incision may course somewhat
toward the submental region or
keep low in the neck, depending on
the surgical requirements.
Retromandibular approach
 Retromandibular approach
• The retromandibular approach exposes the entire ramus from behind
the posterior border of the ramus.

• The approach is useful for procedures involving the area on or near the
condylar neck/head, or the ramus itself
• The distance from the skin incision
to the area of interest is reduced compared
to risdons approach
• Retro-parotid
• Trans-parotid
• Trans massetric
Anterior parotid
 Branches of Facial nerve

• The length of visible facial nerve trunk before

bifurcation is 1.3cm
• Lowest point of EAM to the bifurcation is 2.3cm
• Posterior to parotid gland, the nerve trunk is
atleast 2cm deep to the surface of the skin.
• The marginal mandibular nerve crosses the
posterior border in the lower one third of ramus.
• Hence, this position leaves a void between the
buccal and marginal mandibular branch through
which mandible can be approached safely
Retromandibular vein
• It descends just posterior to the
ramus of the mandible through
the parotid or folded into its deep
aspects.
• RM vein is lateral to ECA
• Both are crossed by facial nerve
Retroparotid approach
• The advantage of this approach is that it avoids the branching
facial nerve which is contained within the parotid gland.

• But then, the advantage of retromandibular approach is lost.

 An oblique incision of approximately
2cm posterior to ramus through skin
and subcutaneous tissue is made,
extending from the mastoid process to
a point just below the angle of the
mandible.

The subcutaneous tissue is

undermined, exposing the superficial
musculoaponeurotic system (SMAS).
An oblique incision is made through
the SMAS. The posterior aspect of the
parotid gland is identified and
dissection continues behind the gland.
The gland is lifted off the
masseter muscle and
retracted anteriorly.

Once the posterior

border of the mandible
has been reached, an
incision is made through
the pterygomasseteric
sling.
A periosteal elevator is used to strip the
masseter muscle from the ramus. Further
dissection superiorly along the posterior
border exposes the condylar process.

The wound is reapproximated in layers

for anatomic realignment and avoidance
of dead space.
The SMAS is resuspended.
The skin and subcutaneous tissues is then
closed
A suction drain may be placed.
Trans parotid approach(Hinds)
• They are further subdivided into
• With facial nerve dissection
• Without facial nerve dissection
 Draping the patient

The incision for the retromandibular

approach begins 0.5 cm below the lobe of the
ear and continues inferiorly 3 to 3.5 cm--
placed just behind the posterior border of the
mandible

The initial incision is carried through skin and

subcutaneous tissues to the level of the scant
platysma muscle present in this area
A scalpel is used to incise through the fusion
of platysma muscle, SMAS, and parotid
capsule in the vertical plane.

Blunt dissection begins within the gland in an

anteromedial direction toward the posterior
border of the mandible. A haemostat is
spread open parallel to the anticipated
direction of the facial nerve branches

The pterygomasseteric sling is incised

sharply with scalpel
The sharp end of a periosteal elevator is drawn along the length
of the incision to strip the tissues from the posterior border of
the ramus, followed by stripping off the masseter from the
lateral surface of the ramus from top to bottom.

The entire lateral surface of the mandibular ramus, up to the

level of the temporomandibular joint capsule as well as the
coronoid process, can be exposed

Closure of the parotid capsule, SMAS and platysma layer is

important to avoid a salivary fistula. A running, slowly
resorbing horizontal mattress suture is used to tightly close the
parotid capsule/SMAS, and the platysma muscle in one
watertight layer. Placement of subcutaneous sutures is followed
by skin closure.
 Protection of parotid duct in trans-parotid
( Retromandibular ) approach
• Parotid gland divided into superficial and deep part based on the
plane of facial nerve and its branches

• The buccal branch of the facial nerve often runs with the duct,
which crosses the superficial layer of the masseter after it exits the
parotid gland

• facial nerve is always lateral to the duct. Thus, if the facial nerve is
properly preserved, the parotid duct would be preserved as well.

Surgical Anatomy of the Parotid Duct With Emphasis on the Major Tributaries Forming the Duct and the Relationship of the Facial Nerve to the Duct† ALAN T. RICHARDS,1
NICHOLAS DIGGES,1 NEIL S. NORTON,2* THOMAS H. QUINN,3 PHILLIP SAY,1 CHAD GALER,1 AND KATHRYN LYDIATT
Transmassetric anteroparotid approach
 Incision marked slightly curved and below
as compared to transparotid approach, 1 cm
below earlobe till gonial angle parallel to
the posterior border of the mandible and
then curved approximately 2 cm anteriorly
below the inferior border of the mandible.

incision placed according to predetermined

incision marking involving skin, platysma
and SMAS.
The parotid capsule was exposed. Then
extensive undermining in horizontal
direction above the parotid capsule parallel
to facial nerve was done to allow maximum
exposure to parotid gland.
 The tail of parotid identified and
retracted posteriorly to expose the
masseter muscle. The masseter
muscle was dissected bluntly using
a haemostat in a vertical direction
to expose the ramus.

closure was done in layers; vicryl 3–

0 used for subcutaneous tissue,
platysma parotid capsule and
pterygomassetric sling. Skin closure
done with simple interrupted
sutures
ALTERNATIVE APPROACHES TO
THE MANDIBULAR RAMUS

• Additional exposure of the mandibular ramus is frequently

required.
• Combinations of approaches such as the preauricular
approach and the retromandibular approach offer increased
exposure for some procedures, such as those for TMJ
ankylosis.
• If even greater exposure is required, these two approaches
can be connected, using a modified Blair incision.
• This incision is used frequently for surgeries involving the
parotid gland, but it is also useful for those involving the
mandibular ramus.
PERIANGULAR APPROACH(Strasbourg
approach 2002)
• A 5-cm curved skin incision is
made 1 cm below the lower
border of the mandible.
• Subcutaneous dissection is
harvested superficially to the
platysma muscle to the level of
interest.
• The platysma muscle is then
cut and carefully retracted, and
the masseteric fascia and the
masseteric muscle are
exposed.
• A branch of the facial nerve
may appear in a split of the
masseteric fascia, originating
from the upper buccal branch.
• Careful dissection is required to
release this branch and retract
it for further dissection. The
dissection remains anterior to
the parotid gland, which should
not be penetrated
• Connective tissue is released, and
the tendon of the masseteric
muscle is cut and crossed to
approach the mandible. This step
allows excellent exposure, even
in cases of high subcondylar
fracture.
• With this approach, the tendon of
the masseter muscle must be cut
so that good exposure is ensured.
Rhytidectomy approach
• Variant of the retromandibular approach

• Deeper dissection - same as that for

retromandibular approach

• Advantage - less conspicuous facial scar

• Disadvantage - additional time required

for closure
Greater auricular nerve
Greater auricular nerve crosses
the SCM muscle at a 45 degree
angle to the mandible, covered
only by the SMAS and the skin
and lies behind the external
jugular vein.
Some branches passes through
the parotid gland and supply the
skin of ear and angle of mandible.
 Begins 1.5 to 2 cm superior to the
zygomatic arch just posterior to the
anterior extent of the hairline; then
curves posteriorly and inferiorly,
blending into a preauricular incision
anterior to the pinna

Continues under the earlobe and

approximately 3 mm onto the
posterior surface of the auricle
instead of continuing in the
mastoid-ear skin crease
 A skin flap is elevated through this
incision using sharp and blunt
dissection and widely undermined to
create a subcutaneous pocket that
extends below the angle of the
mandible and a few centimeters
anterior to the posterior border of the
mandible

The great auricular nerve, which is

deep to the subcutaneous dissection is
the only anatomic structure of
significance in this plane
 Once the skin has been
retracted anteriorly and
inferiorly, the soft tissues
overlying the posterior half of
the mandibular ramus are
visible.

From this point onward, the

dissection proceeds exactly as
the retromandibular approach.
 Deep closure is performed. After
the parotid capsule SMAS platysma
layer is closed, a 1/8- or 3/32-inch
round vacuum drain is placed into
the subcutaneous pocket to
prevent haematoma formation

The drain can exit the posterior

portion of the incision or through a
separate stab in the posterior part
of the neck.
Approaches to TMJ
Approaches to the temporomandibular
joint
• The standard and most basic approach
to the TMJ is the preauricular
approach.
• Other approaches differ in the
placement of the skin incision, as well as
access to the joint.
• The structure that limits the extent of
exposure is the branching facial nerve.
Structures to be protected

• Parotid gland

• Superficial temporal vessels

• Auriculotemporal nerve

• Facial nerve and branches

• Layers of temporoparietal region

Parotid gland
• The superficial pole of parotid gland lies directly on TMJ capsule
• The parotid gland itself is enclosed within the capsule derived from
superficial layer of deep cervical fascia called
PAROTIDOMASSETERIC FASCIA
Diagrammatic “roadmap” representation of head and neck fascial planes. Again the superficial fascia is maroon and the deep
cervical fascia is blue and purple (SLDCF and MLDCF respectively). The superficial and deep fascia are continuous throughout
the head and neck but change names at osseous “intersections.” Note that only the muscular division of the MLDCF is
represented.
Superficial temporal vessels
• It emerges from superior aspect of
parotid gland and accompany the
auriculotemporal nerve.
• As it crosses superficial to zygomatic
arch, a temporal branch is given off
just over the arch – COMMONEST
SOURCE OF BLEEDING.
• Above the arch- divides into frontal
and parietal branches
• Vein lies superficial and posterior to
artery
Auriculotemporal nerve
• Located medial to posterior neck of
condyle.
• Preauricular exposure almost invariably
injures this nerve
• Damage is minimised by incising and
dissecting in close apposition to
cartilageous portion of EAM.
• Temporal extension of the skin incision
should be located posteriorly so that the
main distribution of nerve is dissected and
retracted forward the flap
• Fortunately, patient rarely complaint about
sensory disturbances because of this nerve.
Facial nerve
• As the temporal nerve branches
(frequently two) cross the lateral
surface of the zygomatic arch, they
course along the undersurface of the
temporoparietal fascia.
• Therefore, the temporal branches of
the facial nerve can be protected by
incising through the superficial layer
of temporalis fascia and periosteum
of the zygomatic arch not more than
0.8 cm in front of the anterior border
of the external auditory canal.
 DISTANCE FROM THE LOWEST CONCAVITY OF THE EXTERNAL
AUDITORY CANAL TO THE BIFURCATION OF THE MAIN TRUNK OF
THE FACIAL NERVE IS 1.5 TO 2.8 CM

Atlas of temporomandibular joint surgery – Peter D

FROM THE BIFURCATION OF THE FACIAL NERVE TO
THE POSTGLENOID TUBERCLE – 2.4 TO 3.5 CM

Atlas of temporomandibular joint surgery – Peter D

 THE DISTANCE FROM THE MOST ANTERIOR CONCAVITY OF THE
BONY EXTERNAL AUDITORY CANAL TO THE MOST POSTERIOR
SIGNIFICANT TEMPORAL BRANCH OF THE FACIAL NERVE – 0.8 TO
3.5 CM (MEAN 2CM)

Atlas of temporomandibular joint surgery – Peter D

TMJ
• The disk and its attachments
divide the joint space into
separate superior and inferior
spaces.
• In the frontal plane, the upper
joint space overlaps the lower
joint space. Therefore,
dissection through the lateral
capsule brings one into the
superior compartment.
Pre auricular dissection technique described
in the literature
• Suprafascial procedure
• Rowe NL: Surgery of the temporo-
mandibular Joint. Proc R Soc Med
65:383, 1972
• Subfascial procedure
• Al-Kayat A, Bramley P: A modified
pre-auricular approach to the
temporomandibular joint and malar
arch. Br J Oral Surg 17:91, 1979
• Deep subfascial procedure
• Massimo Politi : J Oral Maxillofac
Surg 62:1097-1102, 2004
 Preparation and draping of surgical site:
expose the entire ear and lateral canthus of
the eye

The incision is outlined at the junction of the

facial skin with the helix of the ear-extends
superiorly to the top of the helix and may
include an anterior (hockey-stick) extension

The incision is made through skin and

subcutaneous connective tissues (including
temporoparietal fascia) to the depth of the
temporalis fascia
 undermine the superior portion of the
incision (that the part above the zygomatic
arch) such that a flap can be retracted
anteriorly for approximately 1.5 to 2 cm

The superficial temporal vessels and

auriculotemporal nerve may be retracted
anteriorly in the flap

Dissection is extended in the same plane

below the level of the zygomatic arch
 Incision made through the superficial layer of
temporalis fascia, beginning at the root of the
zygomatic arch just in front of the tragus,
anterosuperiorly toward the upper corner of the
retracted flap

sharp end of a periosteal elevator is inserted in the

fascial incision, deep to the superficial layer of the
temporal is fascia, and swept back and forth to dissect
this tissue from the underlying areolar and adipose
tissues

undermining proceeds inferiorly toward the zygomatic

arch, where sharp end of the periosteal elevator
cleaves the attachment of the periosteum at the
junction of the lateral and superior surfaces of the
zygomatic arch, freeing the periosteum from its lateral
surface.
 Articular eminence exposed by blunt
dissection 1 cm below zygomatic arch along
plane of initial incision

subperiosteal dissection along the lateral

surface of the zygomatic arch, the
temporal branches of the facial nerve are
located within the substance of the
retracted flap

Temporomandibular joint capsule exposed

• With retraction of the
developed flap, the joint
spaces can be entered
using a scalpel or sharp
scissors after lateral
retraction of the TMJ
capsule.
• Closure is done by suturing the
disk back to its lateral condylar
attachment and then suturing
the incised edge with the
remaining capsular attachments

• If no such attachments are left

attached to bone, the capsule
can be resuspended over the
zygomatic arch to the temporalis
fascia.

• Subcutaneous tissues are closed

with resorbable suture. The skin
is then closed
 MODIFICATIONS OF
PREAURICULAR APPROACH
Blair’s Inverted Hockey Dingman’s Endaural
Stick Incision Incision

Popowich and Crane Thoma’s Angulated

Incision Incision
 ALKAYAT AND BRAMLEY

Skin incision is question mark

shaped

Begins antero-superiorly within the

hairline & curves backwards and
downwards well posterior until it
meets upper ear attachment

Incision then follows ear

attachment endaurally
A modified pre-auricular approach to the temporomandibular joint and malar arch
British Journal of Oral Surgery 17 (1979-80), 91-103
A modified pre-auricular approach to the temporomandibular joint and malar arch
British Journal of Oral Surgery 17 (1979-80), 91-103
 Advantage:

less bleeding
fascial planes can be
easily identified
excellent visibility
good cosmetic
result
 POST AURICULAR APPROACH

 Descibed by Alexander & James

 Incision is placed in the groove between the
helix and post auricular skin
 Pre-op considerations described by Walter
and Geist:
1. History of normal scar formation
2. Healthy auditory system with no
infection
3. No TMJ infection
3-5cm incision is made parallel & Dissection is done through posterior
posterior to postauricular flexure auricular muscle to the level of
mastoid fascia
Begins at superior aspect of external
pinna and extended till the tip of
mastoid process
Transected auditory closure of auditory
canal canal

Final closure of the

incision.
CAPSULAR INCISION

 Once the capsule has been identified, access to

the articular surfaces (superior and inferior
joint spaces) can be obtained by a great variety
of incisions.
HORIZONTAL INCISION OVER THE
LATERAL RIM OF THE GLENOID FOSSA
• The lateral ligament,
capsule, and periosteum
are reflected inferiorly en
masse.
• Discal or posterior
attachment are
dissected sharply with
scissors to the level of
the condylar neck.

;
Peterson’s Principles of Oral and Maxillofacial
The posterior attachment and disc attachments are then severed sharply at the
lateral pole of the condyle from within the developed flap.

These tissues are then reflected superiorly from the head of condyle to expose
inferior joint space 7-Mar-
Peterson’s Principles of Oral and Maxillofacial 17
HORIZONTAL INCISION BELOW THE
LATERAL RIM OF THE GLENOID FOSSA

The superior joint space

is punctured at the
level of discocapsular
sulcus.

A dissection is then carried

inferiorly removing the
attachment of the capsule to the
disc and exposing the inferior
Peterson’s Principles of Oraljoint space.
and Maxillofacial
Peterson’s Principles of Oral and Maxillofacial
T SHAPED INCISION

Peterson’s Principles of Oral and Maxillofacial

SAFEST APPROACH
• Condylar head fractures
Retroauricular approach or deep subfascial preauricular approach
• Condylar neck fractures
Transmassetric anteroparotid with retromandibular approach
• Condylar base fractures
Transmassetric anteroparotid with high submandibular approach
COMPLICATIONS
• Poor facial scar
• Infection
• Wound
dehiscence
• Facial nerve
palsy
• Perichondritis
• Sialocoele
POOR FACIAL SCAR
FACIAL NERVE PARALYSIS
PERICHONDRITIS

SYMPTOMS: pain over auricle and deep in ear canal, edema, erythema,
induration
 MANAGEMENT:

1. Conservative: mildest form is treated by using oral and

topical antibiotics.
2. Hematoma of the auricle should be drained properly
3. If there is any sign of pus drainage – C/S followed by
broad spectrum IV antibiotics.
4. In resistant cases, continuous drainage and irrigation
with antibiotics and steroids solution.
5. In severe cases, aggressive excision of the necrosed
cartilage involving overlying subcutaneous tissues and
skin should be done.
SIALOCELE/SALIVARY FISTULA
 Sialocoeles result in the
accumulation of saliva in
glandular/periglandular
or subcutaneous
tissues.

 When the
accumulated saliva
drain through the
skin it is termed as
salivary fistula.
MANAGEMENT

1. Small sialocoeles have said to resolve spontaneously

by scar formation which seals the salivary flow.

1. Non surgical management:

 repeated aspirations and compression dressings
 administration of anticholinergics
 antisialogogues
 Surgical management:
These procedures direct the salivary flow
into the mouth or
Depresses the salivary secretion

1. Creating a tract intraorally

2. Duct ligation
3. Sectioning of auriculotemporal nerve
4. Surgical excision of fistulous tract
 FREYS SYNDROME

Frey’s syndrome or gustatory sweating and flushing is

characterized by sweating and flushing of the facial skin
during meals.

The area involved is on the lateral aspect of the face and upper
neck, usually around the parotid region.
J Oral Maxillolac Surg49:680-682. 1991 7-Mar-
17
 Minor starch iodine test

 The distribution of the greater auricular nerve and

ATN was painted with a solution containing 3 g
iodine, 20 g castor oil, and 200 mL of absolute
alcohol.
 When dry, the area was lightly dusted with
cornstarch.
 Given lemon drops to chew for 4 minutes to
induce a salivary response.
 A positive test occurs when sweat dissolves the
starch powder and it reacts with the iodine to
produce dark blue spots that may become confluent
 Techniques to evaluate - Blotting paper method
Iodine sublimated paper
histogram

Treatment:
1. external radiotherapy
2. local or systemic application of anticholinergic drugs
Laage-Hellman was the first to apply scopolamine
(3%
cream) for the treatment of gustatory sweating.
3. interposition of a subcutaneous barrier
4. injection of botulinum toxin in the involved skin
REFERENCES
• Surgical Approaches to the Facial Skeleton, Second Edition;
Edward Ellis III, Michael F. Zide
• Surgical Approaches to the Facial Skeleton, First Edition; Edward
Ellis III, Michael F. Zide
• Textbook of Oral and Maxillofacial Surgery, Sixth Edition; Gustav O.
Kruger
• Oral and Maxillofacial Trauma, Third Edition; Fonseca, Walker,
Betts
• Maxillofacial Injuries, Fifth Edition; N. L. Rowe and J. L. Williams
• Modified pre-auricular approach to the temporomandibular joint and malar arch –
Adil Al-Kayat et al; BJOMS 17 (1979-80), 91-103.
• The surgical anatomy of the cervical distribution of the facial nerve – Haithem A.
Ziarah et al; BJOMS (1981), 19, 171-179.
• The surgical anatomy of the mandibular distribution of the facial nerve – Haithem A.
Ziarah et al; BJOMS (1981), 19, 159-170.
• Correlation of temporomandibular joint internal derangements via the posterior
auricular approach – Paul J. Walters and Eric T. Geist; J Oral Maxillofac Surg, 41:616-
618; 1983.
• Surgery of the temporomandibular joint I. Surgical anatomy and surgical incisions –
Keith L. Kreutziger; Oral Surg 58: 637-646, 1984.
• Anatomy of the structures medial to the temporomandibular joint – Nojan
Talebzadeh et al; Oral Surg, Oral Med Oral Pathol Oral Radiol Endod 1999; 88: 674-8.