Original Research

Retromandibular Approach in the treatment

of Subcondylar Fractures
Vijay Ebenezer1, Balakrishnan R2, Abudakir3, Saravana Kumar3

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.

Key words: Subcondylar fracture, Retromandibular approach

Introduction

ractures of the mandibular condyle accounts

for 25-50% of all mandibular fractures.1,2 If
undiagnosed or incorrectly treated, they can lead to
anatomic and functional impairment. Management
of these fractures stimulates more controversy
than any other area of maxillofacial trauma.
Traditionally, closed method for management of
condylar fractures was the treatment of choice.
The rationale for open reduction and internal
fixation in selected cases is that it allows accurate
anatomical reduction of the fractured condylar
process and earlier return to normal function
without the need for intermaxillary fixation.
There are multiple approaches that have been
proposed for the visualization and the reduction
of the condylar fractures including intra-oral, pre-

Professor and Head,

Professor,

Associate Professor,

Department of Oral & Maxillofacial Surgery,

Sree Balaji Dental College & Hospital,
Bharath University, Pallikaranai, Chennai
Corresponding author:
Dr. Vijay Ebenezer,
E mail id: drvijayomfs@yahoo.com

auricular, post-auricular, coronal, rhytidectomy,

retromandibular,
submandibular,
endural,
endoscopic and sometimes in combination.
Each approach has its own advantages and
disadvantages.
The Retromandibular approach is most useful
for all subcondylar fractures and provides the
best access to the joint and ascending ramus. It
was first described by Hinds and Girotti in 19673
and modified by Koberg and Momma in 19784
Originally, Hinds and Kent described it to allow
correction of mandibular prognathism. It has
the advantage of shorter working distance from
the skin incisions to the condyle, great access to
the posterior border of the mandible and sigmoid
notch, less conspicuous facial scar and easy
reduction. The disadvantage associated with this
approach is proximity to the branches of facial
nerve, retromandibular vein and parotid gland.
This approach has become a preferred approach
these days for most of oral and maxillofacial
surgeons. The present study has been undertaken
to treat the cases of sub-condylar fractures
by open reduction and internal fixation using
retromandibular approach and to evaluate the
morbidity associated with this procedure.

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Original Research

Materials and Methods

Five patients with displaced subcondylar fractures
in the age group between 17-35 who reported
to the Department of Oral snd Maxillofacial
Surgery, Sree Balaji Dental College in the year
were included in the study.
Pre-operative clinical examination was supplemented with radiographs like orthopantomographs
and postero-anterior view of mandible. Complete
dental and medical history was taken for the
patient. Medical fitness for surgery was obtained
from a general physician and anesthetist. After
explaining the procedure and its complications to
the patient, informed consent was taken prior to
the surgery. Retromandibular incision was used as
an approach for the management of subcondylar
fractures. The retromandibular approaches expose
the entire ramus from behind the posterior border.
They therefore may be useful for procedures
involving the area on or near the condylar process,
head, or the ramus itself.
There are two types of retromandibular approach
to access the posterior mandible. They differ in
the placement of the incision and the anatomic
dissection to the mandible. The transparotid
approach has the advantage of close proximity
of the skin incision to the area of interest. The
retroparotid approach has the advantage of
not dissecting through the parotid gland. Post
operatively patient was put on proper antibiotics
intravenously for five days, analgesics (NSAID)
for five days, and steroids for two days. Patients
oral cavity was irrigated with normal saline on
daily basis. Patients were called for review at one
week, two weeks and once in three months post
operatively for the next 15 months. During these
visits patients were examined for scar formation
and nerve weakness if any.

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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dissection. Some surgeons advocate placing

an incision approximately 2 cm posterior to
the ramus. The parotid gland is approached
from behind and sharply dissected from the
sternocleidomastoid muscle, allowing retraction
of the gland superiorly and anteriorly to gain
access to the ramus. The theoretic advantage to
this approach is that it avoids the branching facial
nerve, which is contained within the parotid gland.
Unfortunately, the primary advantage of the
retromandibular approach, the direct proximity of
the skin incision to the mandible, is then lost. An
alternate approach, presented here, was described
by Hinds. The incision is placed at the posterior
ramus, just below the earlobe. Dissection to
the posterior border of the mandible is direct,
traversing the parotid gland and exposing some
branches of the facial nerve.

Preparation and Draping

Pertinent landmarks should be exposed throughout
the procedure, keeping the corner of the mouth
and lower lip within the surgical field anteriorly
and the entire ear posteriorly.

Marking the Incision and Vasoconstriction

The skin is marked before injection of a
vasoconstrictor. The incision for the retromandibular approach begins 0.5cm below the lobe of
the ear and continues inferiorly 3 to 3.5 cm. It
is placed just behind the posterior border of the
mandible and may or may not extend below the
level of the mandibular angle, depending on the
amount of exposure needed.

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.

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Original Research

Dissection to the Pterogomasseteric

Muscular Sling
After retraction of the skin edges, the scant
platysma muscle is sharply incised in the
same plane as the skin incision. At this point,
the superficial musculoaponeurotic layer
(SMAS) and parotid capsule are incised and
blunt dissection begins within the gland in an
anteromedial direction toward the posterior
border of the mandible. A hemostat is repeatedly
inserted and spread open parallel to the
anticipated direction of the facial nerve branches.
The marginal mandibular branch of the facial
nerve is often, but not always, encountered
during this dissection. The cervical branch of
the facial nerve may also be encountered, but
it is of little consequence as it runs vertically,
out of the field. In many instances, the marginal
mandibular branch interferes with exposures
and may be retracted superiorly depending on
its location. An useful adjunct in retracting the
marginal mandibular branch involves dissecting
it free from surrounding tissues proximally for
1cm and distally for 1.5 to 2 cm. This simple
maneuver determines whether the nerve is better
retracted superiorly or inferiorly. Dissection
then continues until the only tissue remaining
on the posterior border of the mandible is the
periosteum of the pterygomasseteric sling. One
should also be cognizant of the retromandibular
vein, which runs vertically in the same plane of
dissection and is commonly exposed along its
entire retromandibular course. This vein rarely
requires ligation unless it has been inadvertently
transected.
After retraction of the dissected tissues anteriorly,
a broad retractor such as a ribbon is placed behind
the posterior border of the mandible to retract
the mandibular tissues medially. The posterior
border of the mandible with the overlying
pterygomasseteric sling is visualized.
The
pterygomasseteric sling is sharply incised with a
scalpel. The incision begins as far superiorly as

is reachable and extends as far inferiorly around

the gonial angle as possible. An incision in the
posterior portion of the sling bleeds less than
an incision placed more laterally through the
belly of the masseter muscle. The sharp end of
a periosteal elevator is drawn along the length
of the incision to begin stripping the tissues
from the posterior border of the ramus. The
masseter is stripped from the lateral surface of
the mandible using periosteal elevators. Clean
dissection is facilitated by stripping the muscle
from top to bottom. Keeping the elevator in
intimate contact with the bone reduces shredding
and bleeding of the masseter. The entire lateral
surface of the mandibular ramus to the level of
the temporomandibular joint capsule as well as
the coronoid process can be exposed. Retraction
of the masseter muscle is facilitated by inserting a
suitable retractor into the sigmoid notch channel
retractor, sigmoid notch retractor.

Reduction and fixation

Reduction of the displaced condylar segment was
done with Howarths periosteal elevator. Fixation
was done by mini-plate osteosynthesis. One 4
hole plate (2 mm) with gap, 2x8 mm screws were
used to fix the condyle to the mandible in all the
cases. Wound was debrided using normal saline.

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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visual field and an almost straight line access for

the fixation of the fracture. LYang, P M Patil8
and A.P. Mohan et al9 in 2012 also gave similar
results.
Our clinical study demonstrated no incidence of
temporary marginal mandibular nerve weakness
using this technique, whereas the review of
literature shows that other surgical approaches to
condyle may be associated with high incidence of
temporary facial nerve weakness. As described by
Zide and Kent10 temporal and zygomatic branches
are more prone to damage in rhytidectomy
approach. Incidence of temporary facial nerve
palsy accounts for 11-37% in Risdons approach,
where subplatysmal dissection is performed.11 No
reports of permanent facial nerve damage were
recorded in our study using the retromandibular
approach. There are no reports of permanent
facial nerve damage in the literature also
using retromandibular approach. No patients
developed Freys syndrome in our study till the
follow-up period. No incidence of sialocele was
encountered, that is because of the watertight
closure of the parotid capsule. The resultant scar
was inconspicuous and there were no complaints
regarding it by any patient.

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