This study compared a supratemporalis approach to the traditional preauricular approach for treating intracapsular condylar fractures. 84 patients were treated with one of the two approaches. The supratemporalis approach provided excellent exposure while preventing facial nerve injury, which has a risk of 1-32% with the preauricular approach. No additional complications occurred with the supratemporalis approach. The authors conclude it is an effective routine approach for intracapsular condylar fractures due to its safety advantages over the traditional method.

1. Li H, Zhang G, Cui J, Liu W, Dilxat D, Liu l. A Modified Preauricular
Approach For Treating Intracapsular Condylar Fractures To Prevent
Facial Nerve Injury: The Supratemporalis Approach. J oral maxillofac
surg. 2016 may;74(5):1013-22.
PRESENTED BY –
DR. SHEETAL KAPSE
GUIDED BY –
DR. RAJASEKHAR G.

2. 1. Li H - Resident, Department of Oral and Maxillofacial Surgery, West China
Hospital of Stomatology, Sichuan University, Chengdu, China.
2. Zhang G - Associate Professor, Department of Stomatology, Xinqiao Hospital,
Third Military Medical University, Chongqing, China.
3. Cui J - Attending Staff, Department of Oral and Maxillofacial Surgery, West China
Hospital of Stomatology, Sichuan University, Chengdu, China.
4. Liu W - Resident, Department of Oral and Maxillofacial Surgery, West China
Hospital of Stomatology, Sichuan University, Chengdu, China.
5. Dilxat D - Resident, Department of Oral and Maxillofacial Surgery, West China
Hospital of Stomatology, Sichuan University, Chengdu, China.
6. Liu l - Professor, Department of Oral and Maxillofacial Surgery, West China
Hospital of Stomatology, Sichuan University, Chengdu, China. Drs Li and Zhang
are co-first authors.

3.  Introduction
 Purpose & Aim
 Materials and methods
 Results & Discussion
 Cross references
 Conclusion
 Pros and Cons of study
 References

4.  Condylar fracture is one of the most common fractures in the
mandibular region, with an incidence ranging from 29 to 52%.
 However, condylar fractures are more difficult to handle than other
mandibular fractures because -
1) There are many complex anatomic structures around the condyle in such a
small area;
2) Some serious complications, such as facial deformity and TMJ ankylosis,
can occur;
3) When condylar fractures occur in children, they can cause mandibular
growth disturbance and even severe mandibular deficiencies.

5.  Of these 3 types, the intracapsular condylar fracture is most common,
accounting for 65% of cases.
 More desirable is - not only for anatomic reduction of fragments, but
also for the added insurance of an intact TMJ disc. It also can promote
prompt functional exercise.
 Classic preauricular approach was described by Rowe and others.
advantages, including excellent access to the joint, simple manipulation
of fracture segments, and invisible scar formation.
He D, Yang C, Chen M, et al: Intracapsular condylar fracture of the mandible: Our classification and open treatment
experience. J Oral Maxillofac Surg 67:1672, 2009
Rowe N: Surgery of the temporomandibular joint. Proc R Soc Med 65:383, 1972

6.  However, the facial nerve remains at risk of injury with the preauricular
approach, which cannot be ignored.
 According to well documented reports, the incidence of facial nerve
paresis ranges from 1 to 32% after this surgery.
Hall MB, Brown RW, Lebowitz MS: Facial nerve injury during surgery of the temporomandibular joint: A
comparison of two dissection techniques. J Oral Maxillofac Surg 43:20, 1985
Dolwick MF, Kretzschmar DP: Morbidity associated with the preauricular and perimeatal approaches to the
temporomandibular joint. J Oral Maxillofac Surg 40:699, 1982

7. Purpose :
to prevent facial nerve injury using the
supratemporalis approach in the
treatment of intracapsular condylar
fractures.
The authors hypothesized they could
decrease facial nerve injury in patients
with intracapsular condylar fractures
through a supratemporalis approach.
Aim :
to compare the 2 surgical approaches
for treating intracapsular condylar
fractures with regard to prognoses and
complications and validate the
effectiveness of the supratemporalis
approach presented in this study to
prevent facial nerve injury.

8.  In this prospective cohort study, the population consisted of patients
diagnosed with intracapsular condylar fractures who received surgical
treatment from July 2005 to May 2014.
Inclusion criteria:
• Clinical and imaging diagnoses of intracapsular condylar fractures,
• Have no previous surgical treatment,
• Consent to the surgical treatment,
• Have any of the following fracture types:
1. Displaced fracture in which the ramus stump was dislocated laterally out of the glenoid
fossa;
2. A fracture with reduction of mandibular ramus height;
3. Fracture that caused serious occlusion disorders or an extreme limited maximum
interincisal distance that could not be solved by closed treatment;
4. A fracture that was displaced into the middle cranial fossa.

9.  Patients in the experimental group were treated with the supratemporalis
approach, and patients in the control group were treated with the traditional
preauricular surgical technique.
Exclusion criteria:
1. Undisplaced or only slightly displaced fracture
2. Refused surgical treatment
3. Traumatic scar at the temporal and preauricular regions that would affect placement of
the planned incision
4. Previous facial nerve injury.

10. TECHNIQUE FOR CONTROL GROUP
 n = 40 & 48 sides
 The skin flap consisted of skin, subcutaneous tissue, and superficial
temporalis fascia.

12. TECHNIQUE FOR EXPERIMENTAL GROUP
 n = 44 & 64 sides

13. TECHNIQUE FOR EXPERIMENTAL GROUP

15. 84 patients (112 sides) with intracapsular condylar fractures were
treated surgically (56men, 28women;mean age, 29.85 yr; range, 4 to
70 yr);
44 patients (64 sides)were treated with the supratemporalis approach
and 40patients (48 sides)were treated with the traditional preauricular
approach.
Facial contours and functions recovered well postoperatively in all
84patients.

17.  It should be noted that reductions were ideal and fixations were reliable
in the 2 groups.
 All 84 patients showed substantial improvement in esthetic appearance
and function.
 No patients in either group developed postoperative auriculotemporal
syndrome or wound infection.
 The supratemporalis approach did not increase the frequency of other
complications.

19. Drake MT, Clarke BL, Khosla S. Bisphosphonates: Mechanism of Action and Role
in Clinical Practice. Mayo Clin Proc. 2008 September ; 83(9): 1032–1045.
Osteoporosis
Glucocorticoid-Induced and
Transplant-Associated
osteoporosis
Immobility-Induced Osteoporosis
Other Causes of Acute Bone Loss
Paget Disease of Bone
Malignancy - Breast Cancer,
Prostate Cancer, Multiple Myeloma
Osteonecrosis of the Jaw
Atrial Fibrillation
Over suppression of Bone
Turnover
Hypocalcemia
Acute Inflammatory Response
Severe Musculoskeletal Pain
Clinical Uses Adverse effects

20.  Presented 12 cases with pts age 10.7-17.2
 Most of them were affected with osteoporosis.
 Pamidronate or olpandronate was continued for 2-8 years.
 Normal Linear growth, catch-up growth at puberty, bone biopsy
reports, normal calcium balance, radiographs
 Concluded the bisphosphonates as beneficial treatment option specially
in whom other therapies are ineffective.

21. Babakurban ST, Cakmak O, Kendir S, et al: Temporal
branch of the facial nerve and its relationship to fascial
layers. Arch Facial Plast Surg 12:16, 2010
Dissection of the middle third
of the coronal strip in a fresh
cadaver specimen. The
superficial layer of the deep
temporal fascia (S-DTF)
continues across the
zygomatic arch (ZA) as the
parotideomasseterica
fascia. The temporoparietal
fascia (TPF) continues as the
superficial
musculoaponeurotic system
(SMAS). IFP indicates
intermediate fat pad;
MM, masseter muscle; PG,
parotid gland; SFP,
superficial fat pad.

22.  The temporal branch of the
facial nerve emerged from the
parotid gland below the
zygomatic arch (Figures 6 and
10) and traversed inside the
temporoparietal fascia over the
zygomatic arch following the
Pitanguay line.
 The numbers of temporal
branch twigs passing over the
zygomatic arch were 1 (14.3%), 2
(57.1%), 3 (14.3%), or 4 (14.3%)
in the specimens

23.  Anatomic variations of the temporal branch of the facial nerve make it
vulnerable to injury during surgical dissection in the temporal region.
 The nerve occasionally lies within the superficial temporal fat pad.
 The modification of the skin incision was carried through the deep
temporalis fascia with the fat tissue, exposing the temporal muscle.

25.  Good sample size
 Prospective study
 Long term follow up
 No additional complication
 Overcomes anatomic variations
 Knowledge of dissection planes

26.  The supratemporalis approach provides excellent exposure of the
surgical field with minimal complications.
 Compared with the traditional approach, the supratemporalis
approach effectively prevents injury to the facial nerve.
 Therefore, the authors suggest this surgical method as a routine
approach to treat intracapsular condylar fractures.

27. 1. He D, Yang C, Chen M, et al: Intracapsular condylar fracture of the mandible: Our classification and open
treatment experience. J Oral Maxillofac Surg 67:1672, 2009
2. Rowe N: Surgery of the temporomandibular joint. Proc R Soc Med 65:383, 1972
3. Dolwick MF, Kretzschmar DP: Morbidity associated with the preauricular and perimeatal approaches to the
temporomandibular joint. J Oral Maxillofac Surg 40:699, 1982
4. Hall MB, Brown RW, Lebowitz MS: Facial nerve injury during surgery of the temporomandibular joint: A
comparison of two dissection techniques. J Oral Maxillofac Surg 43:20, 1985
5. Babakurban ST, Cakmak O, Kendir S, et al: Temporal branch of the facial nerve and its relationship to fascial
layers. Arch Facial Plast Surg 12:16, 2010
6. Weinberg S, Kryshtalskyj B: Facial nerve function following temporomandibular joint surgery using the
preauricular approach. J Oral Maxillofac Surg 50:1048, 1992
7. A.W. Wilson,,M. Ethunandan, P.A. Brennan. Transmasseteric antero-parotid approach for open reduction
and internal fixation of condylar fractures. British Journal of Oral and Maxillofacial Surgery (2005) 43, 57—
60.