Page 17 - Demo

General introduction and overview115The ‘standard’ preauricular approach that is often opted for, was designed by Dingman. The incision starts at the helix and runs in the preauricular crease, over the tragal margin to the attachment of the lobule. With time he modified his approach to include a temporal and anterior extension, following a more vertical pre-auricular path. (20) Rowe and Killey developed a similar approach to the first technique by Dingman, starting more superior at the helix and passing front of the preauricular crease.(21) Al Kayat and Bramley further extended the preauricular approach, using a 4 to 6 cm pre-tragal incision, running over the helical root and extending cranially, thus passing behind the superficial temporal artery and auriculotemporal nerve.(22) This incision can be temporally extended if needed, allowing for an easier deep subfascial approach to preserve the temporofacial branch with further exposure of the zygomatic arch and thus glenoid component, which can be needed for the placement of the fossa component of the prosthesis. Whilst adding a Lazy ‘S’ modification to the preauricular approach, to allow for better access to the mandibular angle, could be considered when performing a TMJR, the submandibular approach as suggested by Risdon should be considered. Whilst the marginal ramus of the facial nerve has to be kept in mind during this approach, it allows for a better exposure of the lateral aspect of de mandible and the mandibular angle, thus making it easier to insert and fixate the ramal component of the prosthesis.(19)Besides the preauricular approach, an endaural approach such as the modified Lempert technique by Rongetti could be considered it younger patients, for its cosmetic results, although the surgeon has to be weary not to damage the tragal cartilage.(23,24) The same can be said for the postauricular technique, in which a retro-auricular incision is made, followed by an anterior dissection to reach the TMJ. Taking this approach, the meatus acusticus externus needs to be transected. If this transection occurs too close to the bony auditory canal, risk of stenosis in the cartilaginous part significantly increases, making this technique less preferable for surgeon’s who are new to TMJ surgery. However, in patients prone to keloid formation, this technique should be considered.(19,25)Nikolas de Meurechy NW.indd 15 05-06-2024 10:14