Dr.

Asif Nazir
B.D.S., F.C.P.S. (Oral Surgery)
Senior Registrar,
Oral & Maxillofacial Surgery Department
de’Montmorency College of Dentistry,
Punjab Dental Hospital, Lahore.
Mandibular condylar fractures
29.1 % of all
mandibular fractures.
Mandibular condylar fractures
Mandibular condylar
fractures– a problem
area– difficult to
diagnose, difficult to
approach & difficult to
reduce and stabilize.
Selection of surgical approach
• Level of fracture
Existing laceration
Other associated
fractures
Surgical exposure
required
Cosmetic concerns
of patient
Method of fixation
Surgical approaches
Transcutaneous approaches
Pre-auricular (high condylar #)
Retro-mandibular, trans-parotid
Sub-mandibular (low condylar #)
Pre-auricular approach +/- retro-mandibular
Pre-auricular approach +/- sub-mandibular
Peri-auricular, antero-parotid, trans-masseter
Hemicoronal & coronal approaches
Endoscopic approaches (Skin +/- oral)
Preauricular approach
Dingman’ approach
For condylar head & neck fractures
Incision consists of 2 limbs---one superior and
other inferior to tragus
Incision is placed in pre-auricular crease
through skin s/c tissue to the temporal fascia
Preauricular approach
Then undermining is
done towards the
zygomatic arch
An oblique incision is
made through the tissue
near the root of zygoma
to enter the the joint
capsule and expose the
condylar fracture.
Retromandibular approach
For condylar neck #s &
sub-condylar #s.
Also known as ‘Hind’s
approach’ or ‘Post ramal
approach’
Incision marking
Retromandibular approach
Surgical anatomy
Facial nerve—main
trunk and branches.
Retromandibular approach
Incision is made 0.5cm
below the ear lobe & 1
cm behind the ramus of
mandible
Retromandibular approach
Dissection through skin,
subcutaneous & deeper
tissues & exposure of
parotid capsule.
Retromandibular approach
Dissection through the
parotid gland.
Exposure of posterior
border of ramus of
mandible.
Retromandibular approach
• Marginal mandibulr
nerve retracted postero-
inferiorly.
• Buccal branch retracted
superiorly.
• Masseter muscle is cut
& retracted to expose
posterior border of
mandible.
Retromandibular approach
Fixation of sub-condylar
fracture with miniplate
and monocortical
screws.
Peri-auricular approach
Pre-auricle approach
with different modifi-
cations
1. Retromandibular
2. Lasy ‘S’ modification
3. Rhytidectomy
Peri-auricuular approach
Pre-auricular approach
with lasy ‘S’ extansion
A trans-masseteric
anteroparotid approach
(TMAP).
Dissection in subdermal
fat plane to gain access
to the masseter adjacent
to antero-inferior edge of
parotid gland
Peri-auricuular approach
Trans-messeteric dissec-
tion to expose the
condylar fracture
Reduction of condylar
fracture
Peri-auricuular approach
Fixation of condylar
fracture with two mini-
plates and mono-cortical
screws
Sub-mandibular approach
Also known as risdon approach
Incision is made 2 cm below the angle of
mandible
Skin, s/c tissue, platysma and deep
cervical fascia are incised and dissection
is performed superiorly to expose the sub
condylar fractures
Intraoral (endoscopic)approach
• Mandibular condylar fractures can be best
approached via intra-oral approach with
the help of endoscope.
• Maa and Fang (1994)were the first to use
endoscope for mandibular angle fracture.
• Jacobveiz used it for condylar fractures
first time.
The best surgical approach
Least morbid
No permanent Facial palsy
No Frey’s syndrome
No Salivary fistula / Sialocoele
Little haemorrhage
Good cosmesis
 Excellent exposure & access