British Journal of Oral Surgery 17 (1979-80), 91-103

A MODIFIED PRE-AURICULAR APPROACH TO T H E T E M P O R O M A N D I B U L A R J O I N T AND MALAR ARCH ADIL AL-KAYAT, B.D.S., M.MED.SCI., F.D.S.R.C.S.,1 and PAUL BRAMLEY,M.B., CH.B., B.D.S., F.D.S.R.C.S.2

~Departrnent of Oral Surgery, University of Baghdad; 2Department of Dental Surgery, University of Sheffield
Summary. In an attempt to improve visibility and safety in the surgical approach to the malar arch and jaw joint, anatomical dissections of 56 facial halves were undertaken. Observations are made on the relationship of the facial nerve bifurcation and its temporal branch to bony landmarks. Attention is drawn to the dangerous area of fusion of the superficial fascia, the superficial layer of temporal fascia and the periosteum of the malar arch. The safety of approaching the malar arch through the pocket formed by the splitting of the lower part of the temporal fascia is emphasised. Minor modifications to the established pre-auricular approach were made and applied successfully to six sides in five patients. Introduction Surgical visibility of the jaw joint and malar arch is often compromised by efforts to protect the facial nerve and its branches. Sometimes it can be a bloody operation and the patient be left with a wide area of sensory loss over the distribution of the auriculo-temporal nerve. It is because of the anatomical difficulties and the search for good cosmetic results that there have been so many widely different surgical approaches to the area. The various approaches are listed, (1) Pre-auricular (Risdon, 1934; Blair & Ivy, 1936; quoted by Bellinger, 1940; Milch, 1938; McCann, 1965; Rowe & Killey, 1968; Giles, 1969; Thoma, 1969; Rowe, 1972). (2) Submandibular (Risdon, 1934; Sleeper, 1952; Ward, 1961). (3) Post-auricular (Bockenheimer, 1920; Axhausen, 1931 ; Alexander, 1975). (4) Closed condylotomy (Ward, 1961). (5) Endaural (Rongetti, 1954; Davidson, 1956; Hosxe, 1972). (6) Intra-oral (Keen, 1909; Silverman, 1925; Wielage, 1928; Lewis, 1953; Dingman & Natvig, 1964; Sear, 1972; Quinn, 1977). (7) Horizontal incision along the lower border of the malar arch (Balyeat, 1933; Dingman & Harding, 1951 ; Riessner, 1952; Hueston, 1959). (8) Temporal (Gillies et al., 1927). (9) Through soft tissue laceration or scars (Gillies et al., 1927; Bingham, 1955; Rowe & Killey, 1968). Perhaps the most satisfactory and most commonly used method is the combination of a pre-auricular and endaural approach described by Rowe & Killey, (1968) and Rowe, (1972). In an attempt to find further improvements both in access and safety anatomical studies were undertaken.

(Received 26 September 1978; accepted 3 October 1978)
91

where the most posterior significant twig of the temporal ramus of the facial nerve crosses the arch. The rest of the branches were t h e n dissected f r o m the m a i n t r u n k towards their t e r m i n a l distribution. Point C is the most anterior concavity of the bony external auditory canal. Point Z is the point on the lateral surface of the malar arch midway between its upper and lower border. Table I The age a n d sex d i s t r i b u t i o n of the subjects Age 50-59 60-69 70-79 80-89 90+ No.92 BRITISH JOURNAL OF ORAL SURGERY Materials and methods Observations were made o n 56 facial halves of hard injected cadavers. 1. 1 8 10 7 2 Sex 1M 4M 4F 4M 6F 7F 1M 1F The p a r o t i d a n d t e m p o r a l regions were exposed by using a c o n t i n u o u s incision starting in the t e m p o r a l region as a n inverted J pre-auricular incision a n d c o n t i n u i n g a r o u n d the auricular a t t a c h m e n t a n d d o w n w a r d 2 cm b e h i n d the r a m u s a n d 2 cm below the b o d y o f the mandible. one of the peripheral branches of the facial nerve was identified a n d dissected back towards the m a i n t r u n k . . FIG. Once the p a r o t i d gland was exposed.

: . (2) The distance between point B.)-" G I "" "" i "" i :. t" : ....-. (Fig. 2. Point PG is the lowest point of the post-glenoid tubercle. where the most posterior twig of the temporal ramus of the facial nerve crosses the arch (Fig. and point Z. These three sets of measurements form part of a more extensive investigation which will be more fully reported elsewhere..:" .: . the lowest concavity of the bony external auditory canal. the most anterior concavity of the bony external auditory canal. There was no significant difference between sexes or sides for any measurements and therefore the data from all subjects were grouped.. All measurements were taken by one observer and the accuracy of observations checked against a second observer.A P P R O A C H TO THE T E M P O R O M A N D I B U L A R J O I N T AND M A L A R ARCH 93 In any surgery of this area it is important to know the location of the main trunk o f the facial nerve at its bifurcation and that of the most posterior twig of the temporal ramus of the facial nerve as it crosses the malar arch. . . 2).. ". Data for each measurement were grouped according to sex and side of the head and compared using the Student's t test. 2. ! :. (3) The distance between point P G (the lowest point of the post-glenoid tubercle) and point F.". ." ~..... Point F is the bifurcation of the main trunk of the facial nerve. //ii/[:::12""-. . .) For technical reasons.. :" . i . (1) The distance between point C. .. the point on the lateral surface of the malar arch midway between its upper and lower border.': . The following three sets of measurements were made.. the last two sets of measurements were only carried out in 20 facial halves. and point F.. 1).-':: FIG. .. The bony landmarks chosen were those which could easily be palpated through the skin or during dissection../. Point B is the lowest concavity of the bony external auditory canal. the point at which the facial nerve bifurcates into the temporofacial and cervicofacial divisions (Fig. ..

together with a knowledge of the above measurements.5 Distance (cm) Fla.4 1. at a b o u t 2 cm above the m a l a r arch.5 cm .4 OnOO0 i i i t i 2. t i i 2.7 1.8-3.4 2. Frequency histogram of the relation: a) The bifurcation of the facial nerve to the lowest concavity of the external auditory canal .8 i i i i i .5 cm Range: 0.0 Ho .7 2.5 1.8 2.8 i i ~ 3. this is a single.5 Distance Icm) FIO. b) The bifurcation of the facial nerve to the post-glenoid tubercle . the m e a n a n d the range o f each i n d i v i d u a l measurement.0 1. Results Measurements.1 2.3+0. 5 4 3 -~ 2 E z 1 BFEI PGF I I 1.4-3.2 2.2 3.CZ. Number of observations Mean Range BF 20 2.1 3.0 2. The m e a s u r e m e n t s CZ. They show the n u m b e r of observations. it divides into two layers.6 I . 4.BF. B F a n d P F G are expressed i n frequency histograms (Figs.0 3.4 3. f 1.2 2. Above. one o f which is attached to the lateral a n d the other to the medial cz [] 6 ~5 43E 0.2 1.3 2.5 2.6 2.6 2. thick layer attached to the entire extent o f the superior t e m p o r a l line.8 1. Number of observations: 54 Mean: 2. The temporal fascia.9 3.94 BRITISH JOURNAL OF ORAL SURGERY D u r i n g the dissections. formed the basis of a modified a p p r o a c h to the j o i n t a n d m a l a r arch which was then tried out o n cadavers a n d finally used successfully o n six sides i n five patients.0+0. 3.0+0. i 1.28 cm 1.31 cm 2. 3 & 4).8 cm PGF 20 3. Below. Frequency histogram of relations of the temporal branch of the facial nerve to the anterior concavity of the external auditory canal .9 2.5-2.8 2.5 cm.PGF. .3 3.0 3.6 1. the great i m p o r t a n c e of the detailed a n a t o m y of the t e m p o r a l fascia was recognised a n d this.

The temporal and zygomatic branches of the facial nerve cross the malar arch and lie within this tough connective tissue representing the fusion of the three layers (Fig. 5. Temporal fascia. It is important to note that because o f the anterolateral course of the facial nerve. the periosteum not only firmly blends with the outer layer of the temporal fascia. aspect of the periosteum investing the malar arch (Fig. Superficial fascia. the zygomatic branch of the superficial temporal artery. As the temporal branch ascends in a supero-anterior direction. . The anatomical planes of the branches of the facial nerve. Fatty tissue between the two layers of temporal fascia. and the zygomatico-temporal branch of the maxillary nerve are contained between these two layers. The facial nerve forms a large plexus inside the parotid gland. A small quantity of fat. Arrows point to the joint capsule and the condylar neck. but also with the superficial fascia. In every case. together with the superficial temporal vessels and the auriculo-temporal nerve in the well defined superficial fascia of the temporal region. The relationship of the fascial layers to the malar arch. 5). they lie in the dense fibrous tissues described above. 2. 3.A P P R O A C H TO THE T E M P O R O M A N D I B U L A R J O I N T AND MALAR A R C H 95 Fro. As the nerves ascend to cross the malar arch. 4. 6). 5. Malar arch. 6. it was difficult to dissect out the nerves without some minor damage to them. 1. Medial layer of temporal fascia. the peripheral branches are located more superficially. At the level of the malar arch. it lies. Outer layer of temporal fascia.

8 cm and as far anteriorly as 3.5 cm. anterior to the temporomandibular joint. in terms of surgical safety. Discussion The measurements.4 cm and 3.5 cm and 2. Coronal section through the side of the head. 6. the facial nerve divides and the point of bifurcation lay within 1. The temporo-facial division of the facial nerve and the most posterior filament of the temporal branch always lie anterior to a line drawn between the point of the bifurcation to the post-glenoid tubercle (Fig. Although statistical analysis is useful in checking the accuracy of measurements.8 cm below the lowest concavity of the bony external auditory canal and within 2.5 cm in an infero-posterior direction from the lowest point of the post-glenoid tubercle. These measurements can be used to identify the main trunk and also to avoid it. 2). BF and P G F measurements were designed to investigate the relationship of the bifurcation of the facial nerve with readily identifiable landmarks.scia Epi p fascia Ma of :h FIo.96 BRITISH JOURNAL OF ORAL SURGERY ~alp iscia Ten 'al . The temporo-facial division and the temporal branches. The CZ measurement was designed to establish the safe extent of an incision along the malar arch. At a variable distance from the stylo-mastoid foramen. However. The nerve was on average 2. The main trunk and condylar neck. in individual cases. Protection of the tern- . it is more important to appreciate the extremes of the range o f measurements.0 cm from the anterior concavity of the external auditory canal. the nerve approached as near as 0.

Loeb. Paturet (1951). temporal fascia and superficial fascia. Rouvi6re (1959) and Loeb (1970) have also drawn attention to the relationship of the nerve filaments to the dense fusion of periosteum. 1962. The difficulty we found in dissection of the temporal nerve filaments at the level of the malar arch is consistent with Riessner's (tO52) observations. Fig. but at the price FI~. The temporal fascia must be unequivocally identified and the easy plane o f separation between the temporal fascia and the superficial fascia exploited (Gonzalez-Ulloa. 1970). The arrow points to the plane of separation of the temporal fascia and the superficial fascia. It is therefore essential that the malar arch and temporomandibular joint should be approached deep to this fibrous fusion. A surgical approach The anatomical features described above were applied to an approach to the malar arch and joint which gives excellent visibility with safety. 7 shows that the superficial fascia in the temporal region is a well defined structure and could be confused with the more deeply placed temporal fascia.APPROACH TO THE TEMPOROMANDIBULAR JOINT AND MALAR ARCH 97 poral branch could not be guaranteed if an incision directly down to the malar arch was extended more than 0. 7. . The temporal fascia. either deep to both layers or by exploiting the surgical plane between the two layers of temporal fascia.8 cm in front of the anterior border of the external auditory canal.

The skirt incision is question mark-shaped (Figs. The nerve filaments run in the superficial fascia and it is very important that the full depth of this fascia is reflected with the skin flap. Starting at the root of the malar arch. 10). the periosteum of the malar arch can be safely incised and turned forward as one flap with the outer layer of temporal fascia. 11). It differs from Rowe's (1972) description in the positioning of the skin incision and that through the temporal fascia. Beyond this point there should be no attempt at further dissection of the superficial fascia from the temporal fascia. 8 & 9) and begins about a pinna's length away from the ear. The incision then follows the attachment of the ear and just endaurally as described by Rowe (1972). The pocket formed by the division contains fatty tissue which is easily visible through the thin lateral layer (Fig. Once inside this pocket. superficial fascia containing the nerves and skin (Fig. . an incision running at 45 ° upwards and forwards is made through the superficial layer of the temporal fascia. The pocket can be developed anteriorly as far as the posterior Post branch superficial temporal a ~kin incmion / "" Tragus Lower limit of skin incision • / / Branches of facial n FIG. Skin incision in relation to the underlying structures. 8. antero-superiorly just within the hair line and curves backwards and downwards well posterior of the main branches of the temporal vessels till it meets the upper attachment of the ear. The temporal incision must be carried through the skin and superficial fascia to the level of the temporal fascia.98 BRITISH JOURNAL OF ORAL SURGERY o f a longer incision and wider exposure than is conventional. Blunt dissection in this plane is carried downwards to a point about 2 cm above the malar arch where the temporal fascia splits.

Repair of the layers presents no problems. Skin incision at operation. Care is needed not to extend deep dissection below the lower attachment of the ear. 12). where it is a single layer of tissue. This is in marked contrast to the near impossibility of approximating the temporal fascia if it is incised at a higher level. The incised outer layer of the temporal fascia can be repaired entirely without tension (Fig. A small tortuous branch. The base of the neck of the condyle can be exposed. In all the cadavers and the adult patients the two layers of the temporal fascia and the pocket between them were easily identified. These should be divided and ligated. runs backwards from the superficial temporal artery to the ear.4 cm in an infero-posterior direction from the post-glenoid tubercle. the tissues lateral to the joint capsule are dissected and retracted. 13). Proceeding downwards from the lower border of the arch and articular fossa.APPROACH TO T H E T E M P O R O M A N D I B U L A R JOINT AND MALAR ARCH 99 FIG. The one child in the group had a long . 9. the auricular artery. border of the frontal process of the malar bone and posteriorly joined to the preauricular dissection which follows closely the cartilagenous external auditory canal beneath the glenoid lobe of the parotid gland and the superficial temporal vessels (Fig. The middle temporal artery which comes off the superficial temporal artery perforates the temporal fascia to supply temporalis muscle. The bifurcation of the facial nerve is not nearer than 2.

Arrow points to the fat lobules between the two layers of the temporal fascia. FIG.100 BRITISH J O U R N A L OF ORAL SURGERY Fro. . Coronal section through the side of the head anterior to the temporo-mandibular joint after reflection of the pre-auricular flap. 10. 11.

lateral layer of temporal fascia and superficial fascia as one layer (1). Arrows mark the incision line of the superficial layer of temporal fascia. In this case the two layers could not be distinguished. (1) There is minimal bleeding and less sensory loss. standing bi-lateral ankylosis. The malar arch is exposed after reflecting periosteum. . 12. The muscle is never exposed and the superficial layer of temporal fascia can be closed without tension. (3) There is excellent visibility. The minor modifications of the pre-auricular approach described above have resulted in the following advantages. (2) Fascial places are easily identified. This is partly due to the large flap and partly because the unyielding temporal fascia is not reflected with the skin as in the approach described by Rowe and Killey (1968). The posterior placement of the skin incision and its wide backwards and upwards sweep spares the main branches of vessels and nerves.A P P R O A C H TO THE T E M P O R O M A N D I B U L A R J O I N T A N D MALAR A R C H 10l FIG. (4) The potential complications of muscle herniation and fibrosis are avoided. The need to cut through the combined layer in order to approach the malar arch did not create any problems of repair under tension when carried out at this low level.

Depressed fractures of the zygoma. Acknowledgements We should like to thank Mr R. Tensionless closure of the lateral layer of temporal fascia (2). References Alexander. Balyeat. Arrows show the suture knots. (1940). Sheffield. Sheffield. (7) T h e technique is easily teachable a n d speedily executed. Department of Medical Illustration. Temporo-mandibular joint ankylosis and its surgical correction. Journal of Oral Surgery. W. Elliott. Hallamshire Hospital. 20. G. and Mr P. 713. H.102 BRITISH JOURNAL OF ORAL SURGERY FIG. 13. De operative freilegung des kiefergelenks.o p e r a t i v e d i s c o m f o r t or swelling. F. 27. Cartilage of the tragus marked 1. (6) A g o o d cosmetic result is achieved except in the very bald. 168. 3. Department of Medical Illustration. for their assistance in producing the illustrations. (5) T h e r e is r e m a r k a b l y little p o s t . . Chirnrg. Post-auricular approach for surgery of the temporo-mandibular articulation. R. (1931). American Dental Association Journal. D. (1933). S. (1975). 346. Charles Clifford Dental Hospital. 1563. 33. Bellinger. Cousins. Axhausen. Journal of the American Dental Association.

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