Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 25 (2013) 305309

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Journal of Oral and Maxillofacial Surgery,

Medicine, and Pathology
journal homepage: www.elsevier.com/locate/jomsmp

Original research

A comparative evaluation of the outcome of treating condylar fractures with the

mini retromandibular and the preauricular approaches
Satish K. Pugazhendi a, , Anuradha V b , Lalitha Thambiah a , Kashi Nataraj Vinay c
a
b
c

Annasawmy Mudaliar General Hospital, Bourdillon Road, Bangalore 560043, India

HOSMAT Hospital, Margarth Road, Bangalore 560001, India
Private Practice, Bangalore, Karnataka, India

a r t i c l e

i n f o

Article history:
Received 1 September 2011
Received in revised form 28 April 2012
Accepted 5 June 2012
Available online 20 July 2012
Keywords:
Condylar fractures
Mini retromandibular approach
Preauricular approach

a b s t r a c t
Aim: To compare the outcome of treating condylar fractures with the mini retromandibular and the
preauricular approaches.
Materials and methods: The study group included 31 patients with 36 fractured condyles treated by the
preauricular, and the mini retromandibular approaches among which 26 were unilateral condylar fractures and 5 were bilateral condylar fractures over a time period of 5 years. Treatment outcomes were
evaluated for a minimum of 1 year follow up considering the following parameters: maximum mouth
opening, lateral movement on fractured and opposite side, protrusion, mandibular movements, occlusion,
scar formation, facial nerve weakness and salivary stula, time taken for procedure.
Results: In all cases, occlusion was restored with good anatomical fracture reduction. The mean operating
time was longer in the preauricular group than in the mini retromandibular group. The resultant scar
was satisfactory in almost all patients with the mini retromandibular approach. Pain was lesser in the
mini retromandibular approach. Facial nerve weakness was found in 1 patient out 19 in case of the
mini retromandibular approach in which the whole nerve was lost and 3 patients out of 12 in case of
the preauricular approach in which only the temporal branches of the facial nerve were lost. Complete
recovery of the facial nerve function without any residual weakness was observed in all the affected
patients after 3 months in both the groups.
Conclusion: The mini-retromandibular approach is the best choice as compared to the preauricular
approach because it is extremely easy and fast to perform, presents a very low risk to the facial nerve and
leaves a barely noticeable scar in a relatively hidden region.
2012 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd.
All rights reserved.

1. Introduction
The management of condylar fractures in adults remains controversial. The complication that arise from the surgical approaches
to the condylar neck, and the time consuming nature of the operation inhibits many surgeons from using open reduction and internal
xation for the treatment of the fractured condyle. The many
approaches that have been described bear testimony to the disadvantages of the individual techniques. The most common problems
are limited access to the fracture site and injury to the facial
nerve and resultant operative scar [1]. About 35% of all mandibular fractures are fractures of the mandibular condyle [2]. Attempts

AsianAOMS: Asian Association of Oral and Maxillofacial Surgeons; ASOMP: Asian

Society of Oral and Maxillofacial Pathology; JSOP: Japanese Society of Oral Pathology; JSOMS: Japanese Society of Oral and Maxillofacial Surgeons; JSOM: Japanese
Society of Oral Medicine; JAMI: Japanese Academy of Maxillofacial Implants.
Corresponding author.
E-mail address: arcott21@yahoo.com (S.K. Pugazhendi).

to reach a consensus about the best treatment for fractures of

the mandibular condyle will help patients to be actively involved
in making decisions about their treatment and informed consent
is central to this [3]. Most condylar fractures treated by traditional methods of closed reduction have a reasonable outcome,
but the severity of condylar injuries is often underestimated and
the clinical outcome can be suboptimal particularly with regard
to occlusion. Consequently there has been a trend towards accurate anatomical reduction by open reduction and internal xation
(ORIF) [2]. Condylar fractures account for at least one-third of all
mandibular fractures. Undiagnosed or incorrectly treated condylar fractures can lead to severe functional impairment, including
poor occlusion, reduced mouth opening associated with deviation
of the mandible and limited lateral mandibular movement. Such
fractures can be classied in several ways, but when deciding the
indications for surgical management, the patients age, fracture site
and degree of displacement appear to be of critical importance.
A general consensus holds that intraarticular fractures and others
are better managed conservatively, with short term intermaxillary
xation and intense rehabilitation. Conversely, little agreement

2212-5558/$ see front matter 2012 Asian AOMS, ASOMP, JSOP, JSOMS, JSOM, and JAMI. Published by Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.ajoms.2012.06.001

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exists concerning the management of extra-articular fractures

in adults, with many different protocols that depend mainly on
the surgeons experience and beliefs. Recent publications provide
increasing evidence that surgically treated condylar fractures have
better results in terms of occlusion, masticatory function, mouth
opening and bone morphology. Nevertheless, other studies report a
preference for conservative management because surgical management is technically demanding and involves pitfalls such as facial
nerve injury and unsightly scars [4]. Various surgical approaches
have been proposed for the treatment of these fractures; the submandibular, the preauricular, the rhytidectomy, the intraoral and
the retromandibular approaches and each approach has its advantages and disadvantages. Endoral access which greatly reduces
the risks of facial nerve damage and scars is technically difcult,
requiring special training and dedicated instruments. Conversely,
external access allows straightforward fracture reduction and healing, but risks facial nerve injury and results in visible facial scars [5].
We seek to compare the merits and demerits of the various surgical
approaches to the fractured condyle in our study.
With the advent of rigid xation, more surgeons than ever
favour an open approach to displaced condylar fractures of the
mandible in adult patients, in as much as anatomical reduction and
immediate mobilization of the joint result in a more physiologically sound functioning of the joint. However, the difculties have
been reported in repositioning the condyle and performing accurate placement of the plates and screws; in addition, there is the
possibility of facial nerve injury. Surgeons are constantly seeking
new and improved techniques for efcient reduction and xation.
Several approaches to the management of condylar fractures have
been used including the submandibular approach, the preauricular approach and the retromandibular approach. In addition, a
technique for removal and replantation of the condylar segment
through use of ramus osteotomy has been described [6].
An acceptable operative procedure should fulll the following
criteria [7]:
(1) There must be no operative complication from injury to nerves.
(2) The fractures and dislocations must be reduced so that the
muscles which act on the condyle regain normal tension and
position.
(3) Damage to the attachment of the lateral pterygoid muscle to
the condylar head must be minimized.
(4) Stabilization must be maintainable until bony union occurs.
(5) Restoration of normal function and occlusion should occur
within 612 weeks [7].

June 2005 through June 2010. One of the bilateral condylar fracture
patient was operated on only one side and the associated parasymphysis fracture as he had previous history of chronic renal failure
and increased intraoperative bleeding.
The inclusion criteria for open reduction were subcondylar fractures which were dislocated or displaced. Condylar head fractures
and intracapsular fractures were excluded from the study. The
most important criteria were establishment of occlusion, therefore
even grossly displaced or dislocated fractures were included in this
study.
Unilateral condylar fractures with occlusal derangement where
it is impossible to achieve pretraumatic or adequate occlusion by
closed reduction
Bilateral condylar fractures with resultant anterior open bite
where the option of closed reduction was not feasible
Associated fractures
Unilateral
Bilateral
Other fractures
Patient not willing for intermaxillary xation
Intermaxillary xation contraindicated
3. Mini retromandibular approach
The surgical technique adopted was a mini retromandibular
approach using a skin incision, about 1 cm long, parallel to the
posterior border of the mandible, commencing 0.5 cm below the
earlobe (Fig. 1). Incision was placed using a No.15 BP blade only
for skin. After that, deep dissection was done only with monopolar and bipolar diathermy with blunt dissection in parotid gland
using small curved haemostat. All layers were clearly identied and
undermined on either side of incision to facilitate tension free and
easy closure. The parotid capsule was incised and the gland was
blunt dissected in an anteromedial direction towards the posterior border of mandible. The fracture site on the posterior border of
mandible is identied and the pterygomassetric sling was incised
with diathermy. Under the skin incision the dissection is done from
angle almost to the head of the condyle and a suitable retractor is
inserted into the sigmoid notch to translate the mandible down
to reduce the fracture and to access the condylar fragment easily.
The different parts of the mandible are accessed by sliding the skin
incision up and down.
The fractures were reduced and xation was carried out with
miniplate osteosynthesis using a 1.5 mm osteosynthesis system
which included two plates to secure the condylar fragment to

Though surgery is avoided through closed reduction, the prolonged period of jaw immobility and limited mobility combined
with dietary restrictions with noted decreased ability to maintain
good oral hygiene (especially lingually) and same amount of transient periodontal damage may not make it ideal treatment of choice
in this era of semi rigid and rigid osteosynthesis. The problems indicate a need for faster rehabilitation of the patient towards better
quality of life with minimal or no complications [8].
The two surgical approaches used in our centre are the preauricular approach and the retromandibular approach. We seek to
compare the merits and demerits of these surgical approaches to
the fractured condyle in our study.
2. Materials and methods
The study group included 31 patients with 36 condyles treated
by the preauricular and the mini retromandibular approaches,
among which 26 were unilateral condylar fractures and 5 were
bilateral condylar fractures. The time frame of the study was from

Fig. 1. Incision placed for mini retromandibular approach.

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307

Fig. 2. Fracture site reduced and xed using mini retromandibular approach.

prevent rotation of the fragments during function (Fig. 2). The

condylar fragment was plated rst with the mouth wide open and
later when optimum occlusion was obtained manually the distal
fragment was plated. In some of the cases a wire placed through
the last hole on the plate helped to draw the condylar fragment
into place.
Watertight closure of parotid capsule was achieved during closure. Layered closure with resorbable sutures and skin closure
with non-resorbable sutures was done. Suturing was done subcutaneously using 4-0 nylon or 4-0 monolament sutures.
4. Preauricular approach
The incision was outlined at the junction of the facial skin with
the helix of the ear. A natural skin fold along the entire length
of the ear was used for incision (Fig. 3). The incision was made
through skin and subcutaneous connective tissues (including temporoparietal fascia) to the depth of the temporalis fascia (supercial
layer). This developed ap was dissected anteriorly at the level of

Fig. 4. Fracture site reduced and xed using Preauricular approach.

the supercial (outer) layer of temporalis fascia. Below the zygomatic arch, dissection proceeded bluntly, adjacent to the external
auditory cartilage. At the root of the zygoma, the incision was
made through both the supercial layer of temporalis fascia and the
periosteum of the zygomatic arch. Blunt scissors were used to dissect inferiorly to the zygomatic arch. Once the dissection was about
1 cm below the arch, the intervening tissue was released posteriorly along the plane of the initial incision. The entire ap was then
retracted anteriorly, and blunt dissection at this depth exposed
the articular eminence. With retraction of the developed ap, the
temporomandibular joint is exposed. The fracture is reduced and
xed with miniplate osteosynthesis using a 1.5 mm osteosynthesis
system and again two plates are used to stabilize the fractured fragments (Fig. 4). Subcutaneous tissues were closed with resorbable
suture. The skin was then closed with non resorbable sutures [9].
All patients were reviewed every 3 days for 2 weeks, weekly for
3 weeks and monthly for 1 year to assess:

Maximum mouth opening

Lateral movements on fractured and opposite sides
Protrusive movement
Occlusion
Mandibular movements
Pain (Visual Analogue Scale)
Scar formation
Facial nerve weakness and salivary stula
Time taken for operating procedure

5. Results

Fig. 3. Preauricular incision placed.

The statistical test employed is the t-test. The null hypothesis and the alternate hypothesis were employed and the level of
signicance is taken as 0.05.
We compared the P-value with the level of signicance. If
P < 0.05, we reject the null hypothesis and accept the alternate
hypothesis. If P 0.05, we accept the null hypothesis.

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The pain was evaluated by the use of a Visual Analogue Scale

(VAS) which was a horizontal line, 100 mm in length, anchored by
word descriptors at each end with markings from 0 through 10
and the patient was asked to describe the pain with relation to this
Visual Analogue Scale with 0 being no pain and 10 being extremely
severe pain.
Among the 31 patients 19 patients were treated by the mini
retromandibular approach and 12 patients were treated by the
preauricular approach. Two out of 19 patients and 3 out of 12
patients had bilateral condylar fractures. Dental occlusion was
deranged in all the cases and open reduction with internal xation was done in all cases. The average age of the patients in the
mini retromandibular group was 32.3 years with a range of 2246
years and the average age in the preauricular group was 31.8 years
and the range being 2154 years.
Maximum mouth opening at the end of 3 months was 42.63
(mean) 8.63 (standard deviation) in case of mini retromandibular approach and 47.04 7.00 in case of preauricular approach.
Protrusive movement at the end of 3 months was 4.92 1.88 in
case of mini retromandibular approach and 4.84 1.13 in case of
preauricular approach.
There was a difference in the lateral movements on the fractured and normal sides during the rst post-operative review. A
lateral movement of 4.12 2.08 in case of the mini retromandibular approach and 3.87 1.33 in case of the preauricular approach
was seen on the fractured side. A lateral movement of 6.27 2.76 in
case of the mini retromandibular approach and 6.39 2.13 in case
of the preauricular approach was seen on the normal side.
A statistically signicant difference was found with the pain
factor before and after treatment of condylar fractures.
Pain of 7.18 1.91 in case of the mini retromandibular approach
and 8.86 1.10 in case of the preauricular approach was seen
before treatment. Pain of 1.76 1.17 in case of the mini retromandibular approach and 3.18 1.21 in case of the preauricular
approach was seen after treatment. The presence of mandibular
movement was found to be statistically higher in both the groups
after surgical treatment. No statistically signicant association was
observed in mandibular movements between the groups (P > 0.05).
Two patients in each group had restricted mandibular movements.
Presence of facial nerve weakness was found in 1 patient out of
19 in cases of mini retromandibular approach in which the function
of the whole nerve was lost with palsy in all peripheral branches
including temporal, buccal and marginal mandibular and 3 patients
out of 12 in case of the preauricular approach in which only the
function of the temporal branches of the facial nerve were lost.
All the patients, in both the groups, who were affected by
facial nerve palsy recovered complete function of the nerve in 3
months time. No residual weakness of any peripheral branch of
the facial nerve or the main trunk of the nerve was seen after this
period.
Scar was present in all cases, but almost all patients in the mini
retromandibular group were happy with the scar as the scar was
almost invisible after 1 year (Fig. 5) and in the preauricular group
except 3 patients (out of which 2 patients were mentally handicapped and so were unable to assess the scar and 1 other patient
who was unwilling to assess the scar) all were unhappy with the
scar (Fig. 6).
The mean operating time was found to be of a longer period
63.53 18.12 in the preauricular group compared to 45.22 18.86
in the retromandibular group. The difference in mean operating
time between the two groups was found to be statistically signicant (P < 0.01).
Bilateral closed sialocele was present in 1 patient in the mini
retromandibular approach and was treated by inserting an intraoral drain for a period of 14 days after which there was complete
resolution of the condition.

Fig. 5. Scar formed following mini retromandibular approach, 1 year postoperatively.

Fig. 6. Scar formed following preauricular approach, 1 year post-operatively.

In all cases, the dental occlusion was restored and good anatomical reduction was achieved.
6. Discussion
The treatment of condylar fractures remains controversial
among maxillofacial surgeons. Different surgeons prefer different
approaches based on their experience with the technique and their
personal beliefs. Some favour open reduction and rigid xation
of condylar fractures, while others are against it. Although the

S.K. Pugazhendi et al. / Journal of Oral and Maxillofacial Surgery, Medicine, and Pathology 25 (2013) 305309

preauricular approach is indicated in higher neck fractures, it

allows a less than satisfactory view, especially when dealing with
lower fractures. In addition, the surgeon cannot work perpendicular to the fracture, which makes the procedure somewhat
uncomfortable and sometimes limits rigid xation. The submandibular and retromandibular approaches described in the
literature allow good fracture treatment, but require long skin incisions and present some risk for the facial nerve bres, especially
the marginal mandibular branch [4]. In our case series a total of 4
patients had facial involvement, but there was no case of permanent facial nerve weakness and all the patients were successfully
treated conservatively with steroids, methylcobalaminpregabalin
orally and aggressive physiotherapy. The submandibular approach
offers access at a much lower level and the preauricular approach
offers access at a much higher level in relation to the site of the
fractured condyle.
There was gradual recovery of the nerve over a period of 3
months. We perform the dissection up to the fracture site without
the initial use of muscle relaxants or by use of short acting muscle
relaxants to aid in identifying the proximity to the nerve and later
use long acting muscle relaxants to help in reducing the fracture.
We did not nd the use of the nerve stimulator to be of much use.
We feel that by employing proper dissection techniques based on
intimate understanding of the regional anatomy the facial nerve
may be spared from permanent damage. As all the cases had only
transient facial nerve palsy of a maximum of 3 months before complete recovery we hypothesize that in our case series the damage to
the nerve may have been caused by oedema due over-enthusiastic
retraction of the neighbouring tissues, rather than any active damage to the nerve by manipulation of the nerve trunk itself.
Extra-oral approaches to the treatment of condylar fractures
facilitate better exposure of the operating eld and simplify fracture repositioning compared to the cosmetically more favourable
intra-oral approaches. However, they are still associated with some
unresolved issues such as the potential risk for the facial nerve and
unsightly scars [10]. The preauricular approach is usually preferred
in the treatment of high condylar neck fractures. However, the management of subcondylar fractures by the preauricular approach can
be problematic for treating fractures which are placed at a lower
level as the access granted via this approach is at an angle that is
not comfortable and may thus compromise stabilization [11].
The mini retromandibular approach is a conservative modication of the retromandibular approach mentioned in literature
in that the incision proposed is only 1 cm long as opposed to the
classical 2.53 cm incision. The mini retromandibular approach differs in many details from the preauricular approach. First, the skin
incision is located just posterior to the mandibular angle, is placed
between the buccal and the marginal branches of the facial nerve
and is limited to 1 cm. Then, the subcutaneous dissection allows
extension of the surgical wound to the level of the fracture. Thus, all
the subsequent phases are performed perpendicular to the fracture
ends. It allows the surgeon to work perpendicular to the fracture

309

and thus facilitates the reduction of even medially displaced proximal stumps, which are very hard to manage with other approaches.
In our experience even badly dislocated fracture which are not very
high condylar fractures may be treated via this approach because
only the skin incision is 1 cm long, under the skin incision dissection proceeds from angle of the mandible to the head of the condyle
thereby exposing a large area which may be adequately accessed
by sliding the skin incision up or down as needed.
Furthermore, the articular capsule is never breached, which is
an undoubted advantage to post-operative function, and it gives the
surgeon an optimal view of the bony eld, is very rapid (average
45.22 min) and does not require special training [4].
7. Conclusion
According to recent publications, open reduction and internal
xation of condylar fractures provide better results. The preferred surgical approach should be one that allows straightforward
fracture management whilst minimizing the risk of potential pitfalls, such as facial nerve lesions or unsightly scars. We believe
that the mini-retromandibular approach as compared to the
preauricular approach is the best choice because it is extremely
easy and fast to perform, presents a very low risk to the facial
nerve and leaves a barely noticeable scar in a relatively hidden
region.
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