Antero-parotid Trans-massetric Approach For Reduction Of Mandibular Subcondylar Fractures; Clinical Tricks

Abstract

Introduction: Mandibular fractures in the subcondylar area are frequent in the trauma of the maxillofacial area. This injury is frequent almost at the same rate in adults and children. These fractures are treated by open reduction along with internal fixation or closed reduction. The patient’s age, general health condition, and healthcare setting must be taken into account when deciding on the surgical option. Most of the approaches for open reduction and internal fixation of subcondylar fractures carry the risks of injury to the facial nerve branches and developing sialocele. Although the antero-parotid trans-masseteric approach which was introduced by Wilson in 2005and has the least post-operative complications among other approaches, it is still not widely used by maxillofacial surgeons. The article will give some clinical tricks after ten years of clinical experience, in using this approach for treating about 245 mandibular condylar fractures, on 205 patients. Methodology: This is a retrospective cohort study to evaluate the results of adult population group comprising 205 patients. There were totally 245 fractures of which 205 patients’ surgery was done. Data were gathered from January 2010 to December 2020. Only minimal complications were observed within the first ten days after surgery, including slight transient weakening of the facial nerve, particularly buccal branches, in 3.4 percent of cases and unusual edema and trismus in 8.7% of cases, both of which recovered within the first ten days. In none of these cases, a parotid leak/sialocele was discovered. Discussion: Although the antero-parotid trans-masseteric approach is not widely used between oral and maxillofacial surgeons worldwide, it has the least post-operative complicationscompared to the other approaches for treating mandibular condylar fractures. Data collected from January 2010 till December 2020 with a total of 245 fractures operated on 205 patients. Only minor complications were noticed during the 10 days post operative period with mild temporary weakness of the buccal branches of facial nerve in 3.4% of cases and post operative unusual edema and trismus in 8.7% which resolved during the first ten days post operatively.No parotid leak/sialocele was found in any of these cases. Our aim is to give some clinical tricks after ten years experience in using this approach to treat condylar fractures, to simplifying the technique and to achieve the best results with the least complications. The tricks include the type of fractures that can be treated with this approach, to identify the surgical site, to retract the parotid gland along with its attached fascia posteriorly to open through the masseter muscle, to identify facial nerve branches in surgical site, the needs for perfect retraction and the use of optimum muscle relaxant to aid during reduction ofdisplaced and dislocated subcondylar fractures of mandible. Results And Conclusion: Only minor complications were noticed during the 10 days post operatively with mild temporary weakness of the buccal branches of facial nerve in 3.4% of cases and unusual moderate to severe post-operative facial edema and trismus in 8.7 % which resolved during the first ten days post operatively. No parotid leak/sialocele was found in any of these cases. We recommend this approach as it is rapid, easy, safe, and effective for treating low subcondylar fractures. We suggest considering perioperatively these clinical tricks can achieve the best outcome with least complications and minimize operating time.