Int. J. Oral Maxillofac. Surg.

2012; 41: 930–933

doi:10.1016/j.ijom.2012.02.013, available online at http://www.sciencedirect.com

Clinical Paper
Orthognathic Surgery

Determination of a safety zone A. Gulses1, C. Kilic2, M. Sencimen3

1
2nd Army Corps, Commando Troop No: 5,
Surgical Infirmary, Gokceada, Canakkale,
Turkey; 2Gülhane Military Medical Academy,

for transbuccal trocar Department of Anatomy, Etlik Ankara, Turkey;

3
Gülhane Military Medical Academy,
Department of Oral and Maxillofacial Surgery,

placement: an anatomical study Etlik Ankara, Turkey

A. Gulses, C. Kilic, M. Sencimen: Determination of a safety zone for transbuccal

trocar placement: an anatomical study. Int. J. Oral Maxillofac. Surg. 2012; 41: 930–
933. # 2012 International Association of Oral and Maxillofacial Surgeons. Published
by Elsevier Ltd. All rights reserved.

Abstract. The identification of a safe and accurate technique for facial incisions for
transbuccal approaches to the mandibular angle fractures remains a challenge. An
alternative method of safely and accurately placing the buccal skin incision is
described in this cadaveric study. Thirty-two dissections were performed on 16
bilateral embalmed adult cadaveric heads. In order to identify a safety zone for
transbuccal trocar placement, a triangle shaped zone created by three lines was
determined. The branches of the facial nerve in this zone were reflected by sharp and
blunt dissections. Of 32 sides, marginal mandibular branch was encountered in 1
and marginal mandibular branch and buccal branch of the facial nerve were found in
Keywords: facial nerve; marginal mandibular
2 of the predetermined triangle. In 29 of 32 specimens, the marginal mandibular branch; trocar; buccal branch.
branch was encountered out of the triangle and deep to the platysma muscles. The
triangle determined in the present anatomosurgical study presents an easy Accepted for publication 20 February 2012
identifiable and safe zone for trocar placement. Available online 21 March 2012

Transbuccal trocar placement is widely
used for drill placement and fixation in
the reconstruction of mandibular angle
fractures and stabilization of the mobi-
lized segments during sagittal split ramus
osteotomy procedures. In both cases, a
small extra-oral stab incision was given
to permit the insertion of a transbuccal
canula. Location of the extra-oral stab
incision was guided by the location of
the fracture line and the position of the
facial vessels and facial nerve.1
The transbuccal approach is usually
advocated because it results in no external
scarring and allows direct visualization
and conformation of the desired occlusion
during placement of the bone plates.1
Despite the advantages of this approach,
it has been suggested that transbuccal
trocar technique has limitations. Trans-
buccal trocar placement is technique sen-
sitive and the surgeon has to be familiar
with the armamentarium and be skilled in
the use of the trocar canula.
In the literature, there is some contro-
versy about identifying a safe and accurate
technique for transbuccal incisions.2 It has
been suggested that the surgeon’s inex-
perience will lead to additional facial inci-
sions, especially when access is severely
limited due to the nature of the masseteric
region,3 and that there is a risk of dama-
ging the facial nerve.4
In order to overcome the problems
regarding the identification of an ideal
safety zone for transbuccal placement,
an alternative method of safely and accu-
rately placing the buccal skin incision is
described in this cadaveric study.
Material and methods
This study was based on 32 dissections
performed on 16 bilateral embalmed adult
cadaveric heads from body donation to the
Anatomy Department of the Gulhane
Military Medical Academy. There were
14 males and 2 females of undetermined
age. None of the cadavers had any clinical
evidence of previous mandibular or facial
trauma, surgery, tumour, or any other
maxillofacial pathologic features.
The cadavers were used after obtaining
the appropriate consents and approvals.

0901-5027/080930 + 04 $36.00/0 # 2012 International Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
 Safety zone for transbuccal trocar placement 931

Results
Of 32 sides, the marginal mandibular
branch of the facial nerve (MMBFN)
was found in 3 of the predetermined tri-
angles. The course of the MMBFN in each
case was as follows. In the first case, the
MMBFN entered the triangle through the
corner between the trago-basal line and
cantho-gonial line, crossed the triangle
inferiorly and left it at an angle of 908
to the mandibular line. The buccal branch
of the facial nerve (BBFN) was encoun-
tered adjacent to the corner between the
trago-basal line and the cantho-gonial line
(Fig. 2). In the second case, the MMBFN
entered the triangle through the inferior
third of the cantho-gonial line, and passed
out of the triangle through the distal third
of the mandibular line (Fig. 3). In the third
case, the MMBFN ran parallell to the
inferior border of the mandible (Line 3).
Two buccal branches entered the triangle
Fig. 1. Line 1 (trago-basal line): tragus to the groove over the body of the mandible at the through the upper third of the cantho-
antero-inferior angle of the masseter (the course of the facial artery on the body of the mandible).
gonial line passing out of the triangle
Line 2 (cantho-gonial): outer canthus to the angle of the mandible. Line 3 (mandibular line): the
border of the mandible. through the upper third of the trago-basal
line and anastomosing with the MMBFN
anterior to the triangle (Fig. 4).
All methods for securing human tissue
were humane and complied with the tenets
of the Declaration of Helsinki.
In order to identify a safety zone for
transbuccal trocar placement, a triangle
shaped zone created by the following three
lines was determined (Fig. 1). Line 1
(trago-basal line) ran from the tragus to
the groove over the body of the mandible
at the antero-inferior angle of the masseter
(the course of the facial artery on the body
of the mandible). Line 2 (cantho-gonial
line) ran from the outer canthus to the
angle of the mandible (gonion). Line 3
(mandibular line) was the border of the
mandible.
Dissections of the triangles on 32 pre-
served Caucasian cadaver sides were com-
pleted by the two primary investigators
(A.G. and C.K.). All measurements were
confirmed by both investigators. In pre-
served cadaver heads with overlying skin,
the lines were marked with surgical pens
and the overlying skin on the borders of
the triangle between these three lines was
incised and removed. The nerves in this
zone were reflected by sharp and blunt
dissections. Undermining was carried on
until individualizing the superior and
inferior buccal branches and the marginal
mandibular branch of the facial nerve.
During nerve dissection, the branches
were not separated from underlying tis-
sues. The skinless cadaver heads were
dissected in the same manner after deter- Fig. 2. (A) The facial nerve on the right side (lateral view). (B) Marginal mandibular (M) and
mination of the triangle. buccal (white area) branches of the facial nerve in the triangle.
932 Gulses et al.
Fig. 3. (A) The facial nerve on the left side (lateral view). (B) Marginal mandibular (M) branch
of the facial nervee in the triangle.
In 29 of 32 specimens, the MMBFN was
encountered out of the triangle and deep to
the platysma muscles.
Discussion
The mandibular angle is reported to be the
most frequent site for mandibular fractures
and has the highest rate of complications.5
Two operative techniques that take advan-
tage of the special characteristics of the
angle of the mandible are gaining popu-
larity in clinical practice. They are the
Champy technique,6 which uses two
monocortical miniplates at the alveolar
surface of the angle via the transoral route,
and the lag screw technique which uses
compression7 via a transbuccal approach.8
The transbuccal approach, which was first
described by Kazanjian in 1933, is per-
formed via an intra-oral approach and a
percutaneous stab incision is given extra-
orally in the cheek to facilitate the inser-
tion of a transbuccal trocar achieving lat-
eral plating for which screw are fixed
through the transbuccal canula.1 The main
benefits of the transbuccal approach are
inconspicuous scar formation, direct
visualization of the occlusion during pla-
cement of the bone plates, relatively low
risk of injury to the facial nerve and short
operative time.1
The transbuccal trocar can be applied in
two ways. First, after a small skin incision,
the obturator (within the transbuccal tro-
car) is pushed and rotated forcefully
against the mandible until the tip of the
trocar encounters the buccal mucoperios-
tal flap. Second, after a small incision,
blunt dissection is performed with dissect-
ing scissors or a curved clamp until the
mandibular periosteum is torn and the
trocar is placed through the dissected
channel. The shape and design of the
trocar ensures that it displaces vital struc-
tures such as nerves and vessels away from
the trocar without jeopardizing them. The
authors recommend the second technique,
which is safer.
The MMBFN is responsible for the
motor function of the depressor anguli
oris, the depressor labii inferioris, the
inferior fibres of the orbicularis oris and
the mentalis muscles.9–12 Damaging the
MMBFN can cause salivary incontinence
and aesthetic impairment due to an altera-
tion in the balance of the musculature
around the lower lip, preventing lateral
and downward movement and lower lip
inversion.12,13 Murr suggests that the
transbuccal route is technique-sensitive
and nerve injury is possible.8 MMBFN
contiguity with the safety zone determined
in the current study was found in 3 of 32
triangles (9.3%). Considering the course
of the MMBFNs encountered, two were
located close to the borders of the triangle
and only one (3.1%) MMBFN crossed the
zone, which could present a risk of
damage to the facial nerve. This variation
was previously described by Kirici et al.
with an incidence of 6.25%.14
The incidence of MMBFN anastomoses
with BBFN was 42.22% in the study by
Woltmann et al.12 and 25.8% in the study
by Kirici et al.14 In the current study,
anastomosis of the MMBFN with the
BBFN was encountered in one specimens
and located anterior to the triangle deter-
mined.
During trocar placement, an alternative
pathway lower on the mandible and higher
on the neck is often preferred by many
surgeons. This region is close to the vital
structures (branches of the external carotid
artery, especially the lingual artery, facial
artery and superior thyroid artery) and the
surgeon must have experience with this
region. An advantage of the technique
described here is that the surgical land-
marks are easy to identify. The tragus,
outer canthus and the mandibular angle
are well known landmarks. In addition, the
pulsation of the facial artery could allow
easy identification of the groove on the
mandibular border. Therefore, the techni-
que could be performed easily by inexper-
ienced surgeons and students.
Considering the safety zone for trocar
placement, one might conclude that ana-
tomic structures, such as the parotid gland
and the buccal fat pad, could be in jeo-
pardy. The current study was based on
dissections mainly focused on the topo-
graphy of the facial artery. In most of the
specimens, the parotid gland was located
distally to the cantho-gonial line (Fig. 4b)
and the buccal fat pad was encountered

Fig. 4. (A) The facial nerve on the right side (lateral view). (B) Marginal mandibular (M) and
buccal (white areas) branches of the facial nerve in the triangle.
through the top of the determined triangle,
which is out of surgeons’ preference when
dealing with mandibular angle fractures or
sagittal split ramus osteotomies.
Cole et al.3 have suggested that access
limitations via the transbuccal approach
often leads to additional facial incisions
and that trocar withdrawal into subcuta-
neous tissue followed by repositioning and
deep tissue penetration greatly enhances
operative mobility. The trocar may be
backed out from the masseteric and deep
tissues into more pliable subcutaneous
tissue with little difficulty. Considering
the facial nerve topography encountered
in the current research, one can decide to
perform masseter incision within the
determined safety zone to improve the
operative mobility and avoid possible
scars secondary to additional facial
incisions.
In conclusion, the transbuccal approach
appears in general to be a safe procedure
regarding the facial nerve, but it is impor-
tant to emphasize the importance of the
correlation between the anatomic and
surgical findings and the correct place-
ment of the facial incision. Although the
Safety zone for transbuccal trocar placement
embalmed heads may have had slightly
altered anatomy compared with natural
heads, based on the findings of the current
study, it can be concluded that the triangle
determined in the present anatomosurgical
study presents an easy identifiable and safe
zone for trocar placement.
Competing interests
None declared.
Funding
None.
Ethical approval
This study was carried out after institu-
tional approval obtained from the Ethics
Committee of Gulhane Military Medical
Academy. (No: 1491-435-07/95).
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Address:
Aydin Gulses
2nd Army Corps
Commando Troop No: 5
17760 Surgical Infirmary
Gokceada
Canakkale
Turkey
Tel: +90 5326954048; Fax: +90 3123046020
E-mail: aydingulses@gmail.com