surgical approaches to the mandibular condyle

condyla fracture

2. Dr. Asif Nazir
B.D.S., F.C.P.S. (Oral Surgery)
Senior Registrar,
Oral & Maxillofacial Surgery Department
de’Montmorency College of Dentistry,
Punjab Dental Hospital, Lahore.

3. Mandibular condylar fractures
29.1 % of all
mandibular fractures.

4. Mandibular condylar fractures
Mandibular condylar
fractures– a problem
area– difficult to
diagnose, difficult to
approach & difficult to
reduce and stabilize.

5. Selection of surgical approach
•Level of fracture
Existing laceration
Other associated
fractures
Surgical exposure
required
Cosmetic concerns
of patient
Method of fixation

6. Surgical approaches
Transcutaneous approaches
Pre-auricular (high condylar #)
Retro-mandibular, trans-parotid
Sub-mandibular (low condylar #)
Pre-auricular approach +/- retro-mandibular
Pre-auricular approach +/- sub-mandibular
Peri-auricular, antero-parotid, trans-masseter
Hemicoronal & coronal approaches
Endoscopic approaches (Skin +/- oral)

7. Preauricular approach
Dingman’ approach
For condylar head & neck fractures
Incision consists of 2 limbs---one superior and
other inferior to tragus
Incision is placed in pre-auricular crease
through skin s/c tissue to the temporal fascia

8. Preauricular approach
Then 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.

9. Retromandibular approach
For condylar neck #s &
sub-condylar #s.
Also known as ‘Hind’s
approach’ or ‘Post ramal
approach’
Incision marking

10. Retromandibular approach
Surgical anatomy
Facial nerve—main
trunk and branches.

11. Retromandibular approach
Incision is made 0.5cm
below the ear lobe & 1
cm behind the ramus of
mandible

12. Retromandibular approach
Dissection through skin,
subcutaneous & deeper
tissues & exposure of
parotid capsule.

13. Retromandibular approach
Dissection through the
parotid gland.
Exposure of posterior
border of ramus of
mandible.

14. Retromandibular approach
•Marginal mandibulr
nerve retracted postero-
inferiorly.
•Buccal branch retracted
superiorly.
•Masseter muscle is cut
& retracted to expose
posterior border of
mandible.

15. Retromandibular approach
Fixation of sub-condylar
fracture with miniplate
and monocortical
screws.

16. Peri-auricular approach
Pre-auricle approach
with different modifi-
cations
1. Retromandibular
2. Lasy ‘S’ modification
3. Rhytidectomy

17. Peri-auricuular approach
Pre-auricular approach
with lasy ‘S’ extansion
A trans-masseteric
anteroparotid approach
(TMAP).
Dissection in subdermal
fat plane to gain access
to the masseter adjacent
to antero-inferior edge of
parotid gland

18. Peri-auricuular approach
Trans-messeteric dissec-
tion to expose the
condylar fracture
Reduction of condylar
fracture

19. Peri-auricuular approach
Fixation of condylar
fracture with two mini-
plates and mono-cortical
screws

20. Sub-mandibular approach
Also known as risdon approach
Incision is made 2 cm below the angle of
mandible
Skin, s/c tissue, platysma and deep
cervical fascia are incised and dissection
is performed superiorly to expose the sub
condylar fractures

21. 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.

22. The best surgical approach
Least morbid
No permanent Facial palsy
No Frey’s syndrome
No Salivary fistula / Sialocoele
Little haemorrhage
Good cosmesis
 Excellent exposure & access