British Journal of Oral and Maxillofacial Surgery (2005) 43, 57—60

Transmasseteric antero-parotid approach for

open reduction and internal fixation of condylar
fractures
A.W. Wilsona,∗, M. Ethunandana, P.A. Brennanb

a St. Richard’s Hospital, Chichester, West Sussex PO19 4SE, UK

b Queen Alexandra Hospital, Portsmouth PO6 3LY, UK

Accepted 8 September 2004

KEYWORDS Summary The morbidity that results from surgical approaches to the condylar
Fracture; neck, and the time-consuming nature of the operation inhibits many surgeons from
Mandible; using open reduction and internal fixation for the treatment of condylar fractures.
Condyle; The many approaches that have been described stand testimony to the disadvantages
Access; of the individual techniques. The most common problems are limited access and in-
Approach jury to the facial nerve. We describe the transmasseteric antero-parotid (TMAP)
technique, which offers swift access to the condylar neck while substantially reduc-
ing the risk to the facial nerve and eliminating the complications associated with
transparotid approaches.
© 2004 The British Association of Oral and Maxillofacial Surgeons. Published by
Elsevier Ltd. All rights reserved.

Introduction timony to the shortcomings of most techniques.3

The management of condylar fractures in adults
remains controversial.1 Even with a consensus de-
veloping on the preference for open reduction and
internal fixation of these fractures,2 the clinician
is still faced with the dilemma about an optimal
approach to the ramus-condylar unit. The various
approaches that have been published stand tes-
Limited access and injury to the facial nerve are
the most common problems. We describe a tech-
nique that offers excellent access to the ramus-
condylar unit and is unlikely to damage the facial
nerve.
Technique

A preauricular incision is made that extends down-

* Corresponding author. Tel.: +44 1243 831531;
wards in a curvilinear fashion in the cervicomas-
fax: +44 1243 831544. toid skin crease, though any variation in this in-
E-mail address: alan.wilson@rws-tr.nhs.uk (A.W. Wilson). cision will suffice (Fig. 1). The great auricular

0266-4356/$ — see front matter © 2004 The British Association of Oral and Maxillofacial Surgeons. Published by Elsevier Ltd. All rights reserved.
doi:10.1016/j.bjoms.2004.09.011
58
Figure 1. Preauricular skin crease incision with allowable
modifications: (1) retromandibular; (2) lazy ‘‘S’’ cervico-
mastoid; and (3) rhytidectomy.
nerve is preserved and the flap raised in the sub-
dermal fat plane, superficial to the superficial
musculoaponeurotic layer to allow access to the
masseter adjacent to the anteroinferior edge of
the parotid gland, just below the parotid duct.
Branches of the facial nerve are readily identi-
fied and avoided with or without loupe magnifi-
cation, on the surface of the masseter muscle. A
nerve stimulator may be used if necessary. The
buccal branch is usually the only branch seen (if
any at all) in the area of dissection. The area
next to the anterior edge of the parotid gland
is usually relatively free of branches of the fa-
cial nerve, making this an ideal point to dis-
sect down to the fracture (Fig. 2). If a buccal
branch crosses the field it is easily retracted up or
down.
The masseter is split in the direction of its
fibres, which in the superficial plane run par-
allel to the anterior edge of the parotid. It is
not necessary to sever the fibres to gain ade-
quate access, but this may be necessary as the fi-
A.W. Wilson et al.
Figure 2. Raised flap showing the anterior edge of the
parotid gland and masseter muscle (P: parotid; M: mas-
seter).
bres change direction in the deeper parts of the
muscle. The periosteum overlying the lateral as-
pect of the ramus in the region of the condy-
lar neck is incised and the fracture site is ex-
posed (Fig. 3). If this is not immediately deep
to the incision, it is easily found by gentle re-
traction of the upper edge of the wound. Care
should be taken not to include the condylar head
in this retraction. The fracture is then reduced and
fixed with appropriate plates and screws (Fig. 4).
The wound is closed in layers and a suction drain
left in place for 24 h. Once the technique is
mastered, exposure of the fracture takes about
20—25 min.
Case reports
We have used this approach in three patients,
all of whom had bilateral condylar fractures. Two
patients had preauricular incisions with retro-
mandibular extensions and the third patient had
a lazy-S incision, taking the inferior extension
into the hairline. Postoperatively the functional
Open reduction and internal fixation of condylar fractures
Figure 3. Exposure obtained showing the reduced frac-
ture (M: masseter).
and cosmetic outcome was excellent with no ev-
idence of weakness of the facial nerve, paraes-
thesia of the great auricular nerve, or Frey’s syn-
drome.
Figure 4. Excellent access enables fixation of the frac-
ture with two plates.
59
Discussion
Access with other approaches is often difficult,
which may necessitate forceful tissue retraction
and oblique insertion of the plates and screws. Re-
duction of the medially displaced condylar frag-
ment can be difficult. The most feared compli-
cation common to all other approaches is injury
to the facial nerve, which has been reported to
be temporary in 30—48% and permanent in1%.3,4
The marginal mandibular branch is most often in-
jured in the submandibular and retromandibular
approaches, whereas the preauricular approach of-
ten causes injury to the temporal and zygomatic
branches.
The branching pattern of the extracranial facial
nerve has been described in detail.5,6 There is a
considerably higher incidence of cross-anastomosis
between the branches of the upper division than be-
tween those of the lower divisions. The incidence
of cross anastomosis between the zygomatic and
buccal branches is 87—100%, whereas the marginal
mandibular nerve receives anastomotic branches in
only 0—16% of cases.6 This explains its vulnerabil-
ity in the retromandibular and submandibular ap-
proaches, where no attempt is made to identify the
nerve.3,4 In the TMAP technique, the selection of an
area adjacent the buccal branches and the formal
identification of the nerve neutralises these issues
and as the buccal branch is the only branch normally
encountered (if any at all), its retraction, given
its excellent cross anastamoses, is inherently less
risky.
The incision used in this technique is of
necessity longer than that used in other ap-
proaches. The preauricular element is not cos-
metically important in our experience and the
retromandibular extension can be tailored accord-
ing to the sensitivities of the surgeon and the
patient.
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60 A.W. Wilson et al.

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