Executive Editor: Marcelo Figari, Gregorio Sánchez Aniceto General Editor: Daniel Buchbinder

Authors: Ricardo Cienfuegos, Carl-Peter Cornelius, Edward Ellis III, George Kushner

Mandible

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Glossary

Preauricular approach
The illustration demonstrates the access and the amount of exposure enlarge

Principles

General considerations
The preauricular approach can be used to access and treat fractures in the mandibular condylar head and neck region. Many surgeons perform temporal mandibular joint (TMJ) surgery and routinely use this incision to access the superior portion of the mandibular condylar process.

The illustration demonstrates the access and the amount of exposure.


The vessels should be conserved if possible enlarge

Neurovascular structures
Branches of the facial nerve may be involved in this incision and dissection.
The superficial temporal artery and vein are commonly encountered in this surgical approach. The vessels should be conserved if possible.


Submandibular approach enlarge

Exposure offered by extraoral approaches
Submandibular approach


Retromandibular enlarge

Retromandibular

  • Transparotid
  • Retroparotid

 


Preauricular approach enlarge

Preauricular approach


Facelift incision (rhytidectomy) enlarge

Facelift incision (rhytidectomy)


Skin incision

General consideration
Use of a solution containing vasoconstrictors ensures hemostasis at the surgical site. The two options currently available are the use of local anesthetic or a physiologic solution with vasoconstrictor alone.

Use of a local anesthetic with vasoconstrictor may impair the function of the facial nerve and impede the use of a nerve stimulator during the surgical procedure. Therefore, consideration should be given to using a physiological solution with vasoconstrictor alone or injecting the local anesthetic with vasoconstrictor very superficially.


Make the incision in a preauricular skin crease enlarge

Make the incision in a preauricular skin crease.


Incision to the depth of the temporalis fascia enlarge

Dissection

Locating temporalis fascia
Carry the incision through the skin and subcutaneous tissues to the depth of the temporalis fascia. The temporalis fascia is a glistening white tissue layer that is best appreciated in the superior portion of the incision.

The superficial temporal vessels may be retracted anteriorly with the skin flap (sectioning some posterior and superior branches) or left in place (sectioning frontal branches).

The zygomatic arch can easily be palpated at this point of the dissection. The lateral pole of the mandibular condyle can also be palpated. This can be facilitated by having a surgical assistant manipulate the jaw.


Make an oblique incision parallel to the frontal branch of the facial nerve enlarge

Incising temporalis fascia
Make an oblique incision parallel to the frontal branch of the facial nerve, through the superficial layer of the temporalis fascia above the zygomatic arch.


Insert the periosteal elevator enlarge

Dissection of the joint capsule
Insert the periosteal elevator beneath the superficial layer of the temporalis fascia and strip the periosteum off the lateral zygomatic arch.

Dissection will be carried inferiorly to expose the capsule of the TMJ.


Coronal view of dissection enlarge

Coronal view of dissection to the lateral portion of the zygomatic arch and mandibular condyle region.

Note: the frontal branch of the facial nerve is protected within the superficial layer of the deep temporalis fascia.


Incising the TMJ capsule enlarge

Optional: capsule incision

In the rare case of treating condylar head fractures the TMJ capsule is incised in an open manner.


Dissection can be carried inferiorly in a subperiosteal plane enlarge

Dissection can be carried inferiorly in a subperiosteal plane to reach the neck of the mandibular condyle.
A disadvantage of this approach is that the surgeon can reach only a limited portion of the condylar neck region.


The TMJ capsule must be closed enlarge

Wound closure

If the TMJ capsule has been incised to access the condylar head it must be closed as the first step.


The temporalis fascia is closed enlarge

The temporalis fascia is closed as the next step.

Skin and subcutaneous sutures are placed.

A pressure dressing may be placed over this wound according to surgeon’s preference.

v1.0 2008-12-01