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Official Journal of the Italian Society of Maxillofacial Surgery
Online ISSN 1827-1901
THE TEMPOROMANDIBULAR JOINT
Benech A., Arcuri F., Baragiotta N., Nicolotti M., Brucoli M.
Department of Maxillo-Facial Surgery, Azienda Ospedaliera Maggiore della Carità, University of Piemonte Orientale, “Amedeo Avogadro”, Novara, Italy
Aim. Historically the intracapsular condylar fractures are treated closed because of four main reasons: the technical difficulty to reduce and fix the small fracture segments, the concern about any facial nerve injuries, the potential life-threatening vascular lesions and finally the adequate satisfaction reported by the majority of patients after conservative treatment in long-term follow-up. From the literature, there is a multitude of surgical approaches and technical variants described for gaining direct access to condylar fractures. In 2005 Neff et al., supported by a previous experimental work, published a successful clinical report of condylar head fractures treated by a retroauricular approach; unfortunately, their publication is German and the later English-language literature do not mention about this route to the mandibular condyle. The retroauricular approach, selected and performed by the senior author to treat ten trauma cases, is introduced: this procedure is a relative simple way to gain direct access to fractures of the condylar head, allowing an easy anatomical reduction of the mandibular fragments and a proper osteosynthesis with miniplates and screws.
Methods. We collected data about 10 consecutive adult patients (from January 2006 to December 2008; 7 male patients and 3 female; mean age 32 years) who, after the discussion about all options, had consented to have the mandibular condylar fractures treated with open reduction and internal fixation by the retroauricular approach with miniplates and screws. We exposed the TMJ area easy and better by dissecting via a retroauricular route with identification, ligation and transection of the retromandibular vein; because of the posterior access, the frontal branch of the facial nerve and the auriculotemporal nerve are located and protected within the substance of the anteriorly retracted flap, superficial to the retromandibular vein.
Results. The follow-up clinical examination showed temporary weakness of the frontal branch of the facial nerve in 1 case (10%) with a recovery to normal function of 1.6 months; no patients had neither permanent weakness of the facial nerve nor injury of the auriculotemporal nerve. There was absence of any salivary fistula or sialocele; the ear was preserved in all cases without any auditory stenosis or esthetic deformity and no infections, hematoma or scarring were detected.
Conclusion. Retroauricular approach provides good exposure of the TMJ, satisfactory protection from nerve injuries and vascular lesions allowing and adequate osteosynthesis. The scar is hidden behind the ear and the morbidity is low in terms of auditory stenosis, esthetic deformity and salivary fistulas.