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Novel RetromandibularSubparotideomasseteric Fascial Approachfor Placement of a Temporomandibular

Joint Prosthesis

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Celal Candirli, DDS, PhD,* Fatih Taskesen, DDS, PhD,y Nuray Altintas, DDS, PhD,zand Sadi Memis, DDSx

For placement of a temporomandibular joint prosthesis, preauricular and retromandibular approaches are

used. The main complication of the retromandibular approach is marginal mandibular nerve damage. In

this technical study, the retromandibular subparotideomasseteric fascial approach is introduced as an alter-

native to avoid the complications of the conventional retromandibular approach.

� 2014 American Association of Oral and Maxillofacial Surgeons

J Oral Maxillofac Surg -:e1-e5, 2014

The most common indications for total temporoman-

dibular joint (TMJ) prostheses are arthritis with pain

and ankylosis.1 Many conservative surgical tech-

niques, such as discectomy and arthroplasties, have

been used to treat TMJ disarrangements,2 but inseverely degenerative TMJs these surgical options

may not achieve proper function. In these circum-

stances, a total TMJ prosthesis may be the optimum

treatment method.2

For placement of the fossa component of the pros-

thesis, the preauricular approach is useful.1 For the

ramus and condylar unit, the submandibular and

retromandibular approaches are usually performed.3

It has been well documented that for all of these

approaches, injury of the facial nerve is the main

complication.4,5

Themain advantage of the retromandibular approach

is its closer proximity to the condylar process.6 Howev-

er, there are some disadvantages of the method, such as

passing through the parotid gland tissue, thus

increasing the risk of facial nerve injury and salivaryfistulae.6 Alternatively, various techniques, such as the

transmasseteric or transparotid approaches, have been

reported to yield a safer surgery.6,7

from the Department of Oral and Maxillofacial Surgery,

f Dentistry, Karadeniz Technical University, Trabzon,

ate Professor.

nt.

nt.

ch Assistant.

s correspondence and reprint requests to Dr Taskesen:

nt of Oral and Maxillofacial Surgery, Faculty of Dentistry,

e1

The aim of this studywas to introduce the retroman-

dibular subparotideomasseteric fascial (RSF) approach

as an alternative technique to prevent injury to the

facial nerve and to expose the ramus of the mandible;

in addition, this new technique was compared withother techniques.

Surgical Technique

To reach the angle and ramus of the mandible using

the conventional retromandibular approach, dissec-

tion of the retro-inferior space of the mandible is

needed. The outer to inner layers of the wall consist

of the skin, external fat layer, superficial fascia, pla-

tysma, and superficial cervical fascia.

The superficial cervical fascia contains the retro-

mandibular vein, marginal mandibular nerve, and cer-vical branch of the facial nerve. The anatomy of the

facial nerve and its branches is well documented.8,9

Righini et al4 stated that the cervical and marginal

mandibular branches of the facial nerve emerge at

the anteroinferior part of the inferior parotid gland

and diverge at a highly variable distance from the

parotid gland, although they separate before crossing

Karadeniz Technical University, Trabzon, Turkey; e-mail:

taskesenfatih@gmail.com

Received January 15 2014

Accepted March 20 2014

� 2014 American Association of Oral and Maxillofacial Surgeons

0278-2391/14/00329-2$36.00/0

http://dx.doi.org/10.1016/j.joms.2014.03.016

FIGURE 2. The dissection is carried forward to the parotideomas-seteric fascia.

Candirli et al. Placement of TMJ Prosthesis. J Oral Maxillofac Surg

2014.

e2 PLACEMENT OF TMJ PROSTHESIS

the mandibular angle. Whether the submandibular or

retromandibular approach is performed, the platysma

muscle is incised and the superficial fascia is dissected,

possibly damaging the facial nerve.

For the RSF approach, an incision is made 1 cm

below the ear lobe and 1 cm posterior to the ramus

as in the conventional retromandibular approach.

Then, the skin and superficial fascia are incised. Theskin and the superficial fascia are incised in the same

way in the RSF approach (Fig 1). Contrary to the retro-

mandibular approach, the platysma muscle is not

incised, and the dissection is carried forward to the

masseteric fascia (parotideomasseteric fascia; Fig 2),

after which the parotideomasseteric fascia is incised.

The fascia is incised between the buccal and marginal

mandibular branches of the facial nerve (Fig 3). Afterthe incision of the fascia, dissection is carried back

to the posterior ramal edge under the fascia (Figs 4,

5), after which the masseteric muscle is dissected

from the ramus (Figs 6, 7). Thus, the tissue

compartment that contains the marginal and cervical

branches of the facial nerve is not exposed to reach

the angulus and ramus of the mandible. In addition,

the facial artery and facial and retromandibularveins are not exposed, leading to fewer bleeding

complications than the retromandibular and

submandibular approaches.

FIGURE1. Skin incision line for the retromandibular subparotideo-masseteric fascial approach.

Candirli et al. Placement of TMJ Prosthesis. J Oral Maxillofac Surg

2014.

Report of Cases

In the authors’ department, 9 unilateral TMJ pros-

theses were placed using a preauricular and an RSFapproach from 2011 through 2013. All patients were

treated under general anesthesia and nasotracheal

intubation. All surgeries were performed by the same

surgeon (C.C.). Four patients underwent surgery for

FIGURE 3. Incision line for the parotideomasseteric fascia.

Candirli et al. Placement of TMJ Prosthesis. J Oral Maxillofac Surg

2014.

FIGURE 4. The parotideomasseteric fascia is incised and dissec-tion is carried back to the posterior ramal edge under the parotideo-masseteric fascia.

Candirli et al. Placement of TMJ Prosthesis. J Oral Maxillofac Surg

2014.

FIGURE 6. Dissection of the masseter muscle.

Candirli et al. Placement of TMJ Prosthesis. J Oral Maxillofac Surg

2014.

CANDIRLI ET AL e3

the treatment of osteoarthritis. One patient under-

went surgery for the treatment of displaced condylar

fracture, 1 patient underwent surgery for the treat-

ment of synovial chondromatosis and osteoarthritis,and 2 patients underwent surgery for the treatment

of ankylosis.

FIGURE 5. The masseter muscle appearing after dissection underthe parotideomasseteric fascia.

Candirli et al. Placement of TMJ Prosthesis. J Oral Maxillofac Surg

2014.

No complications, including facial nerve injury,

were seen in any patient. The surgical team experi-

enced more functional and easier dissection by per-

forming RSF approach compared with the classic

retromandibular incision. In addition, surgeons

observed that the RSF approach provided rapiddissection.

FIGURE 7. The masseter muscle is dissected entirely from theramus of the mandible.

Candirli et al. Placement of TMJ Prosthesis. J Oral Maxillofac Surg

2014.

e4 PLACEMENT OF TMJ PROSTHESIS

Discussion

Hinds and Girotti10 described the retromandibular

approach in 1967; Koberg and Momma11 modified

the approach in 1978. Ellis and Dean12 reported a

case series based on the modification of the retroman-

dibular approach. In their study, Ellis and Dean12

reported some advantages of the retromandibular

approach, such as less facial scarring, shorter workingdistance between the facial skin and the condylar

segment, and easier surgical reduction and fixation.

The conventional retromandibular approach requires

retraction of the parotid gland from its inferior or pos-

terior lobe to expose the fracture.13,14 This may cause

facial nerve damage, which has been reported in

almost 30% of cases.7 Manisali et al15 reported that

the injured nerve regained its function 3 months afterthe retromandibular approach. Because of these com-

plications, surgeons have applied modifications to

the conventional retromandibular approach, from

an anteroparotid to a high cervical transmasseteric

approach.16

To reach the ramus of the mandible for the place-

ment of the condylar component of the TMJ pros-

thesis, usually a retromandibular or submandibularapproach is used. Althoughmany articles have focused

on these approaches in connection with the treatment

of condylar fracture, no study has focused on the

placement of the TMJ prosthesis. The present study

details a surgical technique to be used for placement

of the condylar component of the prosthesis.

In the submandibular and retromandibular

approaches, the superficialmusculoaponeurotic system(SMAS) is incised and the tissue compartment that con-

tains the marginal mandibular nerve and cervical nerve

is exposed. In these circumstances, dissection must be

performed carefully to avoid nerve damage from trac-

tion or direct incision. In the RSF approach, the SMAS

of the retromandibular region is not incised, thus pro-

tecting the anatomic integrity of the marginal mandib-

ular nerve, cervical nerve, and retromandibular vein.Alternative transparotid or transmasseteric

approaches used instead of the conventional tech-

nique have been described in the literature.7,17,18 In

these techniques, dissection is performed in the

same plane as the RSF approach. For all these

surgical options, dissection is performed in the

parotideomasseteric fascial plane, which is the facial

continuation of the SMAS; however, the aim of thetransparotid and transmasseteric techniques is to

reach the condylar region of the mandible and

perform open reduction of condylar fractures. Thus,

the dissection should be directed more superiorly.

Therefore, the transparotid and transmasseteric

techniques require facial nerve visualization, unlike

the RSF approach.7

The RSF approach requires incision of the fascia of

the masseteric muscle and posterior tunnel dissection

to the edge of the ramus. This incision region is

between the marginal and buccal branches of the

facial nerve. Therefore, contrary to the transparotid

approach, the main branches of the facial nerve are

not exposed.

Facial nerve anatomy has been well described in theliterature.4 Branches of the facial nerve can be

damaged during surgery.4 In developing the RSF

approach as a modification of the retromandibular

approach, the authors’ primary aim was to decrease

postoperative paresthesia and paralysis from nerve

damage during surgery. This novel technique can be

performed for the open reduction of condylar frac-

tures and to access the ramus region when needed.The patient outcomes of the present study showed

the reliability and shorter surgical durations associated

with the RSF approach.

References

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CANDIRLI ET AL e5

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