Trans-tragal incision for improved exposure of diacapitular and condylar neck fractures

Abstract

The authors present a modification of the preauricular approach that improves the exposure of the condyle whilst reducing diacapitular and condylar neck fractures. The incision is a combination of the hockey-stick and endaural incisions. Its inferior part runs within the ear on the posterior face of the tragus; the tragal cartilage is transected together with the retrotragal skin and included in the anterior skin flap. Between May 2009 and December 2010, 16 patients with diacapitular or condylar neck fractures were treated with this approach. All patients showed good occlusion postoperatively and satisfactory aesthetic results. No infection or cartilage necrosis was observed in this series. This approach improves the exposure of the condylar head during the reduction of diacapitular and condylar neck fractures, ensuring easier internal fixation and good cosmetic results.

The main problem in managing condylar fractures is obtaining adequate exposure to align the bone segments correctly and apply stable internal fixation. Further goals in approaching the temporomandibular joint (TMJ) are minimizing the risk of damaging the facial nerve and obtaining good cosmetic results.

The search for an incision with these features has led to a multitude of approaches . The preauricular approach remains one of the preferred options . This incision seems particularly suited for diacapitular and condylar neck fractures, although even skilled surgeons have to struggle to obtain fragment alignment and fixation if the condylar head or its medial pole is luxated medially. In these cases, the hockey-stick modification can improve the anterior and lateral exposure but does not enhance the exposure of the deep portion of the condylar head . With the detachment of the cartilaginous portion of the external auditory canal (EAC), the endaural incision enables deeper access to the condylar head . The lack of lateral exposure makes it unsuitable for treating TMJ fractures. The authors combined these two incisions, resulting in an incision that enhances the exposure of the condylar process, allowing easier repositioning and stable internal fixation of diacapitular or condylar neck fractures ( Fig. 1 ).

Fig. 1
The modified preauricular approach: the visible part of the incision lies in the preauricular fold and temporal area (blue line); the retrotragal part of the incision runs within the ear (dotted red line).

Materials and method

Surgical technique

The procedure begins in the temporal region. The skin incision starts from a point at the upper end of the preauricular fold in front of the helix and runs for almost 4 cm parallel to the eyebrow in the hair-bearing skin. The temporal incision proceeds downward in the preauricular fold to the upper extremity of the tragus. After incising the skin, subcutis, and temporoparietal fascia, the superficial temporal fascia is identified and exposed. At this point, the incision turns posteriorly, running horizontally into the ear and becoming deeper. After cutting the ligament between the helix and tragus, the tragus is stretched anteriorly with a double hook. The tragal cartilage is cut together with the skin approximately 1 cm medial to its lateral edge. The incision runs downward, describing a half circle down to the inter-tragic incisure ( Fig. 2 ). The cartilage should be cut superficially to the parotid fascia to avoid diffuse bleeding from the gland and to protect the facial nerve.

Fig. 2
Intra-operative view showing how the tragal cartilage is cut 1 cm medial to the lateral edge.

After cutting the cartilaginous framework of the inter-tragic incisure, the incision becomes more superficial, running forward to the preauricular fold. From here, it proceeds downward to the inferior extremity of the ear lobule. At this point, the dissection is continued bluntly down to the superficial muscular aponeurotic system ( Fig. 3 ). The superficial temporal fascia is then incised down to the root of the zygomatic arch, which is dissected subperiosteally to the auricular tubercle. The dissection down to the zygomatic arch proceeds bluntly, detaching the joint capsule from the parotid capsule.

Fig. 3
After cutting the tragal cartilage, the incision proceeds along the preauricular fold downward to the inferior extremity of the ear lobule.

If the parotid capsule is respected, the posterior boundaries of the joint capsule and posterior aspect of the condyle can be exposed without risking direct damage to the facial nerve. The joint capsule can now be opened, and the fracture exposed.

After repositioning the bone fragments and applying internal fixation, the wound in the temporal region and along the preauricular fold is closed in layers. The cut edge of the tragal cartilage is repositioned with two stitches of non-absorbable monofilament passing through skin and cartilage.

Study group

Between May 2009 and December 2010, 16 patients were admitted to the authors’ inpatient department for operative treatment of diacapitular and condylar neck fractures. Their ages ranged from 11 to 62 years. Ten patients were male. All the patients selected for open reduction complained of post-traumatic malocclusion and showed radiological dislocation of the fracture. After nasal intubation, arch bars were placed in all patients. Before starting the surgical procedure, the EAC was packed, and the surgical set, drapes, and gloves were changed to avoid contamination from the mouth and ear. Internal fixation was achieved with miniscrews, miniplates, microplates, or a mixture of these depending on the dimensions of the fractured fragments.

To prevent contamination with bacteria from the ear, the EAC was irrigated with antibiotic solution before suturing. To avoid infections, intravenous antibiotics were administrated intra-operatively. Intra-operative steroids were not administered routinely.

Intermaxillary fixation was applied intra-operatively and left in place for a maximum of 3 weeks, depending on the stability of the internal fixation and patient compliance. Active functional rehabilitation, occlusal guidance with elastics, and soft feeding were continued for 6 weeks postoperatively. The arch bars were removed under local anaesthesia. All patients were recalled 5 months postoperatively to evaluate the results clinically and radiologically. The follow-ups were not performed by the same surgeon.

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Jan 26, 2018 | Posted by in Oral and Maxillofacial Surgery | Comments Off on Trans-tragal incision for improved exposure of diacapitular and condylar neck fractures
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