Page 99 - Open versus closed Mandibular condyle fractures
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Open treatment of condylar fractures: extraoral approaches
In addition to this, Al-Moraissi et al.87 concluded that for condylar head fractures the retro-auricular approach or deep subfascial pre-auricular approach was the safest in terms of protecting the facial nerve, for condylar neck fractures the safest was the transmasseteric anteroparotid approach with retromandibular and pre-auricular extension, and for condylar base fractures they suggested high submandibular incisions with either transmasseteric anteroparotid approach (with retromandibular), or transmasseteric subparotid approach.
Every incision creates a scar. Hiding the scar is an important step in facial reconstruction. Based on the outcomes it can be stated that the risk of unsatisfactory scarring is small and was noted in about 2.4% of patients. Of patients who were dissatisfied with their scar, 31.0% underwent a pre-auricular approach, 28.6% underwent a retromandibular approach, 4.8% underwent a submandibular approach, and a minority underwent another approach (e.g. peri- angular approach or rhytidectomy).
It has been noted that signs of poor pre-auricular incision planning include visible pre-auricular incision lines, an unnatural tragal appearance, and loss of earlobe definition with a ‘pixie-ear’ configuration.88 A rhytidectomy (or facelift incision) produced no unsatisfactory result and, based on this review, could therefore be the incision of preference.
An alternative could be the retro-auricular incision, where the incision is hidden behind the earlobe. Although the complication rates seem to be low,2 strictures of the external auditory canal have been described. The focus of debate is most likely not the choice of skin incision, but rather the choice of subcutaneous dissection.
Based on the literature, use of the transparotid approach has gained popularity as a more straightforward approach, with direct visibility of the fracture and the shortest distance between the skin and the mandibular condyle. Because of the shorter working distance, there is less need to forcefully retract the soft tissues, implying a limited complication rate, in particular with reference to facial nerve weakness.33
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