OOM ANID) | ee a SURGICALANATOMY DISCUSSION ON Retrospective Study of Facial Nerve Injury in Temporomandibular Joint Surgeries Following Preauricular ApproachReview of Basic Anatomy car THE TEMPOROMANDIBULAR JOINT RITERION DESCRIPTION ‘Type of joint ‘Atypical synovial joint ‘Type of synovial joint | Lower compartment — hinge. Upper compartment — gliding ‘Articular surfaces. Mandibular fossa of temporal bone. Condyle of mandible ‘Articular capsular Superior—margins of mandibular fossa. attachments Inferior—mandibular condylar neck. Intrinsic ligament Lateral (TMJ) ligament | Extrinsic ligaments Sphenomandibular ligament, stylomandibular ligament Articular disc Divides joint space into separate upper and lower compartments Retrodiscal pad Highly vascularized posterior attachment of diso—fills space created as disc glides anteriorly Main movements— Hinge motion between condyle and dise during mandibular elevation/depression lower compartment” Main movements— Dise-condyle complex glides on posterior surface of articular eminence during elevation/depression uppercompartment’ _| and protrusion/retrusion * between articular disc and condyle ** between disc-candyle compiex and mandibular fossa of temporal bone ood Grispian Scully. Oral Anatomy. in: Oxford handbook of applied dental sciences. Oxford OX2 6DP; 2002:65PE 5 ee «The anatomical structures around TMJ must be understood to avoid damage to important structures. = The success of any TMJ procedure depends on the type of procedure, the area of penetration, and the anatomical knowledge and skill of the surgeon eet) Deer MLM ten A eB ge eg eRe Ca oe ee of the tj. In: McCain JP, ed. Principles and Practice of Temporemandibular joint arthroscopy. Sa enc ere aedPE ery 1-1.5 cm eee eee oe Cee ee Sra ete eee) pee ety erly Skin leet) eee Bera ee Se ae Ce oe ae me cr De ae ALLPEG ery ets Ey wall Pe erect EN eee erg Ean erly Skin leet) les Bera ee Se ae Ce oe ae me cr De ae ALLPEG ery 25% ret rues Pe eres tect rece ES erly Skin leet) eee Bera ee Se ae Ce oe ae me cr De ae ALLPEG ery (Va Pec Cue rues Pe eres teed Neca ietrg ES erly Skin leet) eee Bera ee Se ae Ce oe ae me cr De ae ALLPEG ery era OZ) Ce ee wal Pere ret Pei eee as erly Skin leet) eee Bera ee Se ae Ce oe ae me cr De ae ALLEy 9 Peary = Approaches to the joint include the following Sie aca ele ie aCe e 1) « Postauricular = Rhytidectomal (Face lift) = Submandibular (Risdon) = Retromandibular (Hinds) « Intraoral eae FR eee Na ge Tg lee eee Oe Tae erie rece Ree aces ease) ee Oe eo eee h ee ee ferret es se en ee te eg a re PeePa Ty) Peary = Ideally, the selected approach should accomplish the following: = Maximize exposure for the specific procedure = Avoid damage to the branches of the facial nerve = Avoid damage to major vessels Sea auc, See ary = Avoid damage to the parotid gland = Maximize use of natural skin creases for cosmetic wound closure ete Quinn PD. surgical approaches to the temporomandioular joint. In: color atlas of temporomandibular eerEE TT Peery = The main potential anatomic problems in temporomandibular joint surgery are = the facial nerve and Se Caleta MONET kom RCT ere) 0 nn eee Quinn PD. surgical approaches to the temporomandioular joint. In: color atlas of temporomandibular jointsurgery.FACIAL NERVE =. “(iPa 13 Peary = Serious morbidity from facial nerve injury can overshadow the mechanical improvements in joint function and the amelioration of painful symptoms. ete CO Me CR ee Denese ae enerFaisal H Rana SCM aa CET) nerve exits from the skull at the ReneS cae SUE Mn ML Ld tympanic and mastoid portions CRUE CEO Neely anatomic landmark because the EO eats Rui? SCR ONC MCCUE UL) ECan uE er) ToesPeery = Approximately 3 cm of the facial nerve is visible until it divides into telco Ca ReePeary UCR SSee Ue eRe CeeACum Ge) BUR Seon! rest ckueie cur nae nme uh neniice cun eno] to be 1.5 cm to 2.8 cm (mean, 2.3 cm), and the distance from the postglenoid tubercle to the bifurcation was 2.4 cm to 3.5 cm (mean, 3.0 cm) “Temporal facial division Main trunk of / fociol nervePeary The most variable measurement was the point at which the upper trunk crosses the zygomatic archPeary It ranged from 8 mm to 35 mm anterior to the most anterior portion of the bony external auditory canal (mean, 2 .0 cm). By incising the superficial layer of the temporalis fascia and the periosteum over the arch inside the 8 mm boundary, surgeons can prevent damage to the branches of the upper trunk.20 Peary The temporal branch of the facial nerve emerges from the parotid gland and crosses the zygoma under the temporoparietal fascia to innervate the frontalis muscle ("corrugaror muscle") in the forehead. Loose areoler tissue layer Frontal branch of facialnevre Zygomatic arch >arottgomasseterte fascia Pees Stuzin JM, Wagstrom L, Kawamoto HK, Wolfe SA. Anatomy of the frontal branch ofthe facial nerve: the Pica iet cme Cec tm nk pet seaal= BUT PEF PeeryPd Peary = There are reports stating that the frontal nerve crosses the zygomatic arch in a deeper plane, just over the zygomatic arch periosteum. = Regardless of the precise level where the nerveis positioned, the fusion of planes at this level risks ETN Ua Culaia CMLL Ng Recess Owsley J, Agarwal CA (2008) Safely navigating around the facial nerve in three dimensions. Clin Plast ier oe iad Sree Weiser eee eect cae eee Pee ae eae arenes co tem a eres Sees eae)4128/2016 Faisal H Rana The trajectory of the frontal nerve corresponds to a line named “Pitanguy line” that starts from a point 0.5 cm below the tragus and runs to a point 1 cm above the lateral edge of the eyebrow es Pitanguy I, Ramos AS (1966) The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg 38(4):352-356Ey Pz) Peary = Postsurgical palsy manifests as an inability to raise the eyebrow and ptosis of the brow. = Damage to the zygomatic branch results in temporary or permanent paresis to the orbicularis oculi and may require temporary patching of the eye to prevent corneal desiccation and abrasion. = Permanent nerve damage may necessitate tarsorrhaphy before a more permanent functional approach, such as implantation of a gold weight for gravity-assisted closure of the upper lid, can be used.7 a “Ii VASCULAR ANATOMY = The external carotid artery terminates in two branches: = the superficial temporal and = internal maxillary arteries. = The superficial temporal artery and vein are routinely ligated daring preauricular approaches SB UM UID MO SIT aaleLE encountered unless condylectomy is performed= The course of the superficial temporal artery at the scalp is the part of its course over the zygomatic arch «As the artery comes from Cm CEU Tacx [Col aaa} found passing over the posterior root of the zygomatic process. Faisal H Rana Superficial Temporal ArterySUIT 7 Faisal H Rana Superficial Temporal Artery ST a mm CMU Ly temporoparietal fascia, and as it continues branching, it becomes more superficial Eli MeCm mac [Wold Mtoe Chtome || Superficial Temporal Artery =It runs upward giving off some branches and finally bifurcates into the frontal (anterior) and parietal (posterior) final branches.Pa 29 Faisal H Rana Superficial Temporal Artery = The bifurcation of the superficial temporal artery into its terminal frontal and parietal branches occurs above the zygomatic arch in the majority of the individuals (60-88 %)vm ” | ero Superficial Temporal Arte uperficial Temporal Artery = Bifurcation at the level of the arch has been reported to range between 4 and 26 %, whereas bifurcation below the arch ranges between 8 and 11 % of individuals Reus Cree COR cu Ree eeu al. 1986 ; Czerwinski 1992 ; Nakajima et al. 1995 ; eee mee ML Re een Rac Tae Prvm | ero Superficial Temporal Arte uperficial Temporal Artery = Rarely, in approximately 3.7 % of cases, the artery does not bifurcate and courses only as a frontal etme RU Lec Melee mee leg Reese (Pinar YA, Govsa F (2008) Anatomy of the superficial temporal artery and its branches: its importance for surgery. Surg Radiol Anat 28(3):248-253)4128/2016 Peery When the bifurcation of the superfi cial temporal artery occurs above the zygomatic arch, it happens at a point within 2-4 cm above the arch. At the branching point, the diameter of the artery is approximately 1.8—2.7 mm. Rocca Stock et al. 1980 ; Marano et al. 1985 ; Abul-Hassan et al. 1986 ; Chenet al. 1999 ; PinarandGovsa 2006 ErMaxillary Artery = The larger of the 2 terminal branches of the external carotid Elica = Arises posterior to the condylar neck of the mandible within the parotid gland. = It crosses medial to the condylar neck and sigmoid notch and has been found to be on average 20 mm below the head of the condyle = Exits the parotid gland and passes anteriorly between the ramus of the mandible and the sphenomandibular lig. within the infratemporal fossa34 Peary = Takes a course thatis either superficial or deep to the lateral pterygoid until reaching the pterygopalatine fossa via the reefer DCMI IIK = Supplies the deep structures of the face and may be divided into 3 parts as it passes medially through the infratemporal fossa: = 1st part—mandibular part = 2nd part—pterygoid part = 3rd part—pterygopalatine partPeary The maxillary artery arises at the neck of the mandible and is divided into three parts by the lateral pterygoid; it can pass medial or lateral to the lateral pterygoid. rep tengral artes eye ay A. ate Yew36 Peary The branches of the first or retromandibular part pass through foramina or canals: the deep auricular to the external acoustic meatus, the anterior tympanic to the tympanic cavity, the middle and accessory meningeal to the cranial cavity, and the inferior alveolar to the mandible and teeth. Met tery A. ate YewEa 37 Peary The branches of the second part (directly telated to the lateral pterygoid) supply muscles via the masseteric, deep temporal, pterygoid, and buccal branches.38 Peary The branches of the third (pterygopalatine) part (posterior superior alveolar, infraorbital, descending palatine, and sphenopalatine arteries) arise immediately proximal to and within the pterygopalatine fossaNow lets disscuss todays. ° | ARTICLE = RETROSPECTIVE STUDY OF FACIAL, ata ELS a Cem ere eas FOLLOWING PREAURICULAR APPROACHRetrospective Study of Facial Nerve Injury in Temporomandibular Joint Surgeries Following Preauricular Approach apanet 40 Rajasekhar G”, Kruthi N?, Nandagopl V' and Sudhir R? Faisal H Rana " Department of Oral and Maxilofacial Surgery, Mamata Dental Colege and Hospital, india ? Karthik Superspeciaity Hospital, India Abstract Purpose ‘The at of te present study is to.evaliate the facial nerve function folie wing surgeries ofthe temporommandibulat {bint through pteabricular approach, with the objectives of identifying the commonly affected branch of facial nerve ‘andthe time taken for resolution of weakness and occurrence of any permanent nerve damage. Methods A itrespetlilé evaluation was done on 2\paHehIS who reported to Mamata Dental College and Hospital, Khammam, Inca, from Jul2070 KS Vine! 2013 who underwent various surgical procedures of temporomandibular joint through pre auricular approach. Facial nefve Weakness Wes assessed both at rest and in function through House and Brackman Facial Nerve Grading System (HBFNGS) during 24 hours, 1 week, 1 month, 3 months and 6 ‘months and ‘year postoperatively and the results were summarized Results 20GUL6FS2 patients hac facialnerve weakness folowing surgery 60% ofthe palienis had recovered nofialmotor function of facil nerve 1 month postoperatively, 94.44% have regained normal function 3 months postoperatively. ‘At year post operative period all the patients (100%) have regained normal motor nerve function. Temporal and zygomatic branches were involved most commonly, Time taken for resolution of weakness was more for temporal branch, Conclusion Facial nerve! Weekes folowing’ preauricuar approach ls nly temporary andl ros common causes are stretching and compression ofthe nerve. Preaurcular approach is consieted sefe and cosmetic.Keywords: Facial nerve; Pre auricular incision; House and Brackman facial nerve grading system; Temporal ;Zygomatic Introduction Facial nerve is considered the (Quella THA FAQ” as it innervates the muscles of facial expression, Anatomic variations and multiple Innervation pattems of the peripheral branches render facial nerve to an increased risk during verious surgical procedures to temporomandibular joint using preauricular apprcach [1] Fala neh {injury following various surgical procedures to the maxillofacial region ranges from 0-48% || Incidence of facial nerve injury following TM strgeres ranges from 1-32% [2). Out of the several methods used for evaluating the motor function of facial nerve, Howse aid Back Facial Nerve Grading System (HBENGS) has gained some importance ‘which was introduced in 1983 and modified by Brackmann in 1985 and accepted by American Academy of Otolaryngology and Head and Neck Surgery (3). tis a comprehensive method of evaluation of, motor function, both at rest and in function. It carries an interobserver reliability of 93% (3). Motor impairment of the facial nerve has severe emotional impact ‘on patients both in terms of function and esthetics. We have noticed that there is 0 proper consensus on the incidence of facial nerve damage and the time taken for the resolution of the symptoms in this ppartof the country, Hence, the authors have undertaken the following study with the aim to evaluate the facial nerve function following surgery through preauricular incision that would contribute to the previous literature, increase awareness among the surgeons and as well as help them in assuring the patients undergoing surgery in the region of temporomandibular joint. The objectives of the current study are to identify the commonly afected branch of facial nerve, the time taken for resolution of the weakness and incidence of any petmanent nerve damage. Material and Methods FRERORPRAANE data was collect from a total of 32 patients who reported to Mamata Dental College and Hospital, Khammam, Andhra Pradesh, India, during &peiod of3 yeas from July 2010to June 2013. ‘who underwent various surgical procedures to temporomandibular joint using preauricular approach (Tablel), Ethical clearance was obtained from the institute and informed consent was taken from all the patients Patients who had facial nerve weakness pre operatively Wate excluded from the study, Facial nerve weakness post operatively vwasassessed both at rest and in function through House and Brackman Facial Nerve Grading System (HBENGS) during 24 hours, 1 week, 1 4/28/2016 Faisal H Rana ‘Corresponding author: Rajasekhar G, Professor and Head, Department of (ral and Maxil‘acial Sugery, Mamata Dental College and Hosp, Khammam, ‘Anda Pradesh, India, Tl 99000018128, E-mail. ax/ace2007@gmail com Received Apri 20, 2014, Accepted May 27,2014, Published May 30,2014 Citation: Rajasekhar G, Knuth N, Nandagopl V, Sudhir R (2014) Retrospective Study of Facal Nerve injury in Temporomandibular Jont Surgeries Folowng Preaunedlar Approach. Anaplastology 3: 132, dot 10.4172/216'-1173 1000132 Copyright: © 2014 Rajasehhar G etal. This is an open-access atl dstbuled Under the terms of the Creative Comirons Attibutton License, which permts, unvestcted use, csrbuton, and reproduction in any medium, provided the orginal author and source ae credited.32 1VRF LEFT CONDYLAR# ROWES ‘Shows numberof patients iudéd in the study, wit their demographic data of age, sex, agnosis, incision given and tre facial nerve branch / branches affected ‘Table 1: List of the Patients included in the Study. 1/28/2016 42 Faisal H Rana month, 3 months and 6 months and Iyear postoperatively (Table 2). of which ATEN@yat and Bramley inelston vas given in I cases Rowels Statistical analysis was done by Friedman Test and Wilcoxon Signed incision in 22 cases. dol test wing SPSS alia verdon 172 In a total of 32 patients, 20(6305%) ad facial inetve Weakness following surgery. During frst 24 hours following the surgery, 10 out of 20 patients (50%) showed moderately severe dysfunction while 6 patients (30%) showed moderate dysfunction and 4 patients (20%) hhad mild dysfunction of the facial nerve, The results are summarized in Table 2, At * month post operative period, 12 out of 20 patients (60%) had recovered normal motor function of facial nerve. Two patients could not be reviewed for more than 1 month post operatively as they did not turn up for futher follow up, thus attring the sample size to 18 (n=18) at months pos operative period and on follow up iD UHRPASA WEES PHGLOGAPHRA in the following positions: at Fest, while closing the eyes with minimal effort, hile trying to close the eyes with maximum effort, raising the eyebrows, blowing the cheeks and smiling or showing the lower anterior teeth and the results were simmarized, When both temporal and zygomatic branches were involved, grading was given based on the ability to close the eye. Results Cut of the 32 patients, SPEER ete ci gnosedtONhave temporomandibular joint ankylosis, of which bilateral ankylosis was ‘seen in case 1. There were 22 cases of condylar fracture in which 3 cases had bilateral involvement of facture and one case of condar Hyperplasia was also included A total of 36 surgical approaches were carried out on 32 patients with modifications of pre auricular incisions affer 3 months 17 patients out of 18 (94.44%) regained normal facial nerve function and at 6 months post operative period all except one patient regained motor function wile the remaining Ipatient had mild temporal branch weakness without affecting the function of closure of the eye. At 1! year post operative period, all the 18 patients (100%) recovered normal motor function, ‘eopstgy ISS 216-179 Anapaslogy, a open aces oul Volume 3+ Issue 1+ 1000182