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Abstract
This study was carried out to assess the versatility of the retromandibular approach in the management of subcondylar
fractures. Five patients underwent open reduction and internal fixation of their subcondylar fractures using retromandibular
approach. Retromandinular vein was encountered in one case (17%). None of the patients had a temporary deficit of
facial nerve but there were no signs of permanent nerve injury in any case.
Introduction
Professor,
Associate Professor,
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Original Research
Procedure
The retromandibular approach to the mandible
varies with surgeons in the position of the skin
incision, which also dictates the underlying
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Skin Incision
The initial incision is carried through skin and
subcutaneous tissues to the level of the scant
platysma muscle present in this area. Undermining
the skin with scissor dissection in all directions
allows ease of the retraction and facilitates
closure. Hemostasis is then achieved with electro
coagulation of bleeding subdermal vessels.
Original Research
Closure
The masseter and medial pterygoid muscles
are sutures together with interrupted resorbable
sutures. It may be difficult to pass the suture
needle through the medial pterygoid muscle
because it is very thin at the inferior and posterior
borders of the mandible. To facilitate closure,
the edge of the medial pterygoid muscle can be
stripped for easier needle passage. Closure of
the parotid capsule/SMAS and platysma layer is
important to avoid salivary fistula. A running,
slowly resorbing horizontal mattress suture is
used to tightly close the parotid capsule, SMAS,
and platysma muscle in one watertight layer.
Placement of subcutaneous sutures is followed
by skin closure with 4-0 proline.
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Original Research
Results
There were five patients; all were males with a
mean age of 28 years in the range of 17-35 years.
All patients had unilateral condylar fractures. In
two of the cases the Condyle is displaced medially.
Two patients had other associated fractures of
the mandible, 1 angle and 1 parasymphysis.
All the patients were treated by open reduction
and internal fixation using the retromandibular
approach as an access to the condyle. The time
taken for the complete procedure was 1 hour 40
minutes (or) a little less than that in all cases.
During the procedure the marginal mandibular
nerve branch of facial nerve was not encountered
in any of the case. The retromandibular vein was
encountered in 1 case which was safely retracted
posteriorly. None of the patients had any form of
facial nerve weakness during the post operative
review. Occlusion was achieved intra operatively
in all the five cases.
Discussion
While treating the sub-condylar fractures
surgically, many authors have given different
approaches. Edward Ellis, Throckmorton, Hyde,
Stuart Hislop were the few surgeons who used
retromandibular approach for open reduction
and internal fixation for managing subcondylar
fractures. They concluded that it is an effective
technique that gives good exposure and it is safer
also as the incidence of facial nerve weakness is
lesser as compared to other approaches and also
the incidence of hypertrophic scar is less and the
scar so formed is inconspicuous.
S. Bindra et al5 suggested retromandibular
approach for open reduction of mandibular
condylar fractures as it is associated with low
morbidity and adequate exposure of the fracture
site in 2010. Vijay Ebenezer and R. Balakrishnan6
in 2011, JorgHandschel et al7 in 2012 compared
the various approaches for rigid fixation of
the sub-condylar fractures and concluded that
retromandibular approach provides a more direct
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References
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Anil Sheorain , C. B. Sharma : Management of
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Original Research
Using Retromandibular Approach and Assessment
of Associated Surgical Complications. J. Maxillofac.
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3844
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Schwarz , Ulrich Meyer, Norbert R. Kbler , Christian
Naujoks : Comparison of various approaches for the
treatment of fractures of the mandibular condylar
process. Journal of Cranio-Maxillo-Facial Surgery
(2012) 1-5
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