Original Article

Minimizing the Submandibular Incision in

Endoscopic Subcondylar Fracture Repair
Yasser Abdallah Aboelatta, MD1 Amir S. Elbarbary, MD1 Sarah Abdelazeem, MSc1
Karim S. Massoud, MD1 Ikram I. Safe, MD1

1 Department of Plastic & Reconstructive Surgery, Ain-Shams Address for correspondence Amir S. Elbarbary, MD, Department of
University, Cairo, Egypt Plastic & Reconstructive Surgery, Ain-Shams University, Ramsees St.
Abbasia Cairo 11566, Egypt (e-mail: amir_elbarbary@yahoo.com;
Craniomaxillofac Trauma Reconstruction amir_elbarbary@med.asu.edu.eg).

Abstract Endoscope-assisted treatment of mandibular condylar fractures is an evolving surgical

technique of this controversial subject. The approach is performed through an intraoral
and additional submandibular incision. This study presents a technique for minimizing
the length of the optional submandibular incision. Ten patients with displaced
subcondylar fractures and malocclusion underwent endoscope-assisted open reduction
and internal fixation (ORIF). A limited (<1 cm) submandibular incision (dissected under

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endoscopic guidance from within) was needed in eight patients to complement the
intraoral incision and facilitate the reduction in the fractures. Satisfactory small scar
Keywords could be obtained in all patients with neither wound complications nor facial nerve
► fracture mandible injuries. Our technique depends on dissection first then incision. Performing the
► subcondylar fracture external incision after complete intraoral dissection is safe for the facial nerve and
► facial fracture minimizes scarring markedly. This very limited submandibular incision facilitates
► malocclusion reduction in relatively difficult cases and enables clear visualization of posterior border
► endoscopy of the mandible to confirm adequate fracture reduction.

Fractures of the mandibular condyle are very common and to use an additional submandibular incision to reduce a
account for 9 to 45% of all mandibular fractures.1–4 Despite difficult fracture displacement.
this fact, the controversy in their management remains as This pilot study presents a modified surgical technique for
common as their incidences. Although closed treatment is the minimizing the submandibular incision to only few milli-
method most commonly used, anatomic reduction is rarely meters during the endoscopic treatment of mandibular con-
accomplished.1 Open reduction and internal fixation (ORIF) is dyle fractures. This technique relies on complete intraoral
needed for proper anatomic condylar segments alignment. dissection first then making the external incision. This limit-
Classically, ORIF is achieved through external approaches ed incision makes the procedure effective and easy to
such as the retromandibular, or a combined preauricular perform.
and submandibular approach. Nevertheless, complications
including damage to the facial nerve and the creation of
Patients and Methods
visible scars hinder its wide acceptance. Intraoral approaches
to the mandibular condyle can reduce the risk to the facial This study included 10 patients (7 males and 3 females)
nerve and eliminate facial scarring1 but they lack the ade- presenting with posttraumatic mandibular subcondylar frac-
quate access for proper reduction and fixation. Endoscope- tures admitted to Plastic Surgery Department at Ain-Shams
assisted treatment of condyle fractures offers an appealing University Hospitals and underwent endoscope-assisted
alternative to overcome both problems and limitations while mandibular condylar fracture over a period of 1 year from
achieving ORIF. However, with the exception of pure intraoral January 2013 till December 2013. The patients’ mean age was
approach advocated by Schön et al,1 most surgeons still need 28
12 years. Five patients had associated mandibular

received Copyright © by Thieme Medical DOI http://dx.doi.org/

April 13, 2014 Publishers, Inc., 333 Seventh Avenue, 10.1055/s-0035-1549010.
accepted after revision New York, NY 10001, USA. ISSN 1943-3875.
December 27, 2014 Tel: +1(212) 584-4662.
Minimizing Submandibular Incision in Endoscopic Subcondylar Fracture Repair Aboelatta et al.

fractures and two patients had other associated maxillofacial done over the tip of the dissector and the external incision
fracture. The anatomical distribution of the mandibular frac- was connected with the intraoral incision. An interosseus
tures is shown in ►Table 1. All patients were referred from the wire was introduced through a drill hole at the angle of the
emergency department after exclusion of other associated mandible. Traction was applied using this wire that facilitated
trauma. History taking and physical examination were per- the reduction and maintained the fractured segments in
formed to confirm the diagnosis. Preoperative radiographs proper anatomical alignment. Fixation was then achieved
were done including panoramic X-ray and CT scan facial using 2.0 miniplates applied through the intraoral incision
bones with thin cuts and 3D reconstructions. and percutaneous miniscrews. Intraoral incision closure,
Patients with displaced subcondylar fractures (fracture release of MMF, and ensuring that proper occlusion has
line passing at or just below the deepest level of the sigmoid been achieved completed the procedure.
notch that allows for placement of two screws on the proxi- The patients were instructed on soft diet for a couple of
mal segment of an adult mandible) and malocclusion were weeks. The occlusion of the patient was rechecked on the
included in the study. Exclusion criteria comprised intra- second postoperative day and the arch bars were removed
capsular, comminuted, and condylar head fractures, patients within the first week if the occlusion was satisfactory. Follow-
presenting with fractures without malocclusion, and those up was scheduled weekly in the first month then postopera-
with associated comorbidities such as cardiopulmonary dis- tive visits were arranged at 3 and 6 months. Assessment
orders, bleeding tendency, or patients receiving antiplatelet included evaluation of occlusion and measurements of maxi-
or anticoagulant medications. mal incisal opening. Any clinical symptoms such as pain,
All surgical procedures were done by the same surgical clicking, TMJ dysfunction, or the presence of any abnormality
team. Upper and lower arch bars were applied first, followed in mouth opening were recorded. Postoperative radiographs
by intraoral exposure of any other associated fractures. ORIF were obtained immediately following the surgical interven-

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was achieved using 2.3 plates and screws. Exposure of the tion and at 6 months postoperatively.
affected condylar segment was done by an intraoral incision Scar assessment criteria were adopted from the Patient
along the anterior border of the mandibular ramus. Intraoral and Observer Scar Assessment Scale (POSAS) and The Stony
subperiosteal dissection was performed till an adequate Brook Scar Evaluation Scale.5,6 The assessment criteria in-
optical cavity was developed. A 4-mm, 30-degree rigid endo- cluded scar erythema, height, width, pigmentation, pliability,
scope (Karl Storz, Germany) fitted with either a standard pain, itching, or pruritus that interferes or not with quality of
endoforehead sheath or a specialized intraoral sheath retrac- life, and scar visibility to patient’s relatives.
tor was used. Subperiosteal dissection was performed along
the lateral side of the ramus till the whole posterior border is
Results
exposed. Subperiosteal dissection of the proximal segment
was performed exposing the whole neck and subcondylar Comparison of preoperative mouth opening (24
8 mm)
area as far as the capsule of the temporomandibular joint and postoperative mouth opening (40
7 mm) showed
(TMJ). In cases where endoscopic ORIF could be achieved highly significant improvement (p < 0.001). Furthermore,
through the intraoral incision alone, the procedure was there was also statistically significant improvement in re-
completed and closure of the intraoral incision was done. corded pre- and postoperative clinical findings, including
If reduction in the fracture could not be achieved, an pain, clicking, mouth deviation, and occlusion (p < 0.05).
additional modified submandibular incision was used. The This clinical improvement was also confirmed radiologically,
intraoral dissection was extended inferiorly toward the angle which revealed also statistically highly significant improve-
of the mandible under endoscopic guidance till the pterygo- ment between pre- and postoperative radiographs
masseteric sling is reached. Blunt dissection of the soft tissue (►Fig. 1, ►Table 2).
toward the angle of the mandible and parallel to the direction The intraoral exposure was adequate to complete the
of the facial nerve was performed, guided by the tip of a procedure in two patients whereas the minimized subman-
periosteal elevator pushing the pterygomasseteric sling dibular incision was needed in eight patients to achieve
through the intraoral incision. Upon reaching the skin at fracture alignment and proper occlusion. Scar assessment
angle of the mandible, a small stab incision (<1 cm) was revealed that no patient had hypertrophic scars, widened
scars, scar dyspigmentation, and no associated symptoms
Table 1 Anatomical distribution of mandibular fractures
such as pain or pruritus. Scars were slightly firm in early
postoperative follow-up. However, all scars were nearly not
Variables Patients
felt at all at 6 months follow-up. In addition, all patients had
Bilateral subcondylar 1 satisfactory results with overall good scar appearance.
Right subcondylar 2 Regarding scar visibility, no patient had visible attracting
Left subcondylar 7 scar, four patients had visible scar to patient’s relatives from
near distances, and four patients had nearly nonvisible scars
Right body fracture 1
even from near distances (►Fig. 2).
Left parasymphyseal 2
Regarding postoperative complications; the patient with
Right parasymphyseal 1 bilateral subcondylar fracture had a minimal anterior open
bite and mouth deviation postoperatively that was corrected

Craniomaxillofacial Trauma and Reconstruction

 Minimizing Submandibular Incision in Endoscopic Subcondylar Fracture Repair Aboelatta et al.

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Fig. 1 (a) The extraoral incision is performed over the tip of the dissector after complete intraoral dissection, and an interosseus wire is applied
and used for traction to facilitate reduction. (b) The endoscope is applied through the extraoral incision to visualize the posterior border of the
mandible clearly. (c) The extraoral incision 2 weeks postoperative. (d) Pre- and postoperative CT scan coronal views.

by the use of class II guiding dental elastics worn at night for Discussion
1 month. Another patient with an associated parasymphyseal
fracture had a minor midline shift and was managed similarly The management of mandibular subcondylar fractures re-
by class II guiding elastics worn at night for 1 month. In mains controversial.7 Although closed reduction and MMF is
addition, intraoral parasymphyseal (not intraoral condylar) the most commonly used treatment, it showed a higher
wound dehiscence occurred in one patient that required percentage of anatomic displacement when compared with
secondary suturing. ORIF.8 In addition, it is associated with higher complications

Craniomaxillofacial Trauma and Reconstruction

Minimizing Submandibular Incision in Endoscopic Subcondylar Fracture Repair Aboelatta et al.

Table 2 Statistically significant radiologic improvement among incisions.13,16–26 The advantage of the intraoral approach is
patients (McNemar test) the absence of skin incision, but the optical cavity is smaller.
The submandibular approach requires a 1.5-cm skin incision
Variables Group II, n ¼ 10 at the angle of the mandible, similar to a Risdon incision,
Panorama pre-op placing the facial nerve at minimal risk. However, the optical
No displacement 1 (10%) cavity created has a larger working space with better endo-
Displacement 9 (90%) scopic orientation.27
Panorama post-op Lee and colleagues28 presented the results of 20 patients
No displacement 9 (90%) who underwent endoscope-assisted ORIF. They used an
Displacement 1 (10%) intraoral approach with a transfacial portal. However, one
p <0.001 HS patient had facial nerve palsy. In 1999, Lauer and Schmel-
CT pre-op zeisen11 used a 2- to 3-cm submandibular incision and two
No displacement 1 (10%) additional facial portals in four patients. In 2001, Honda and
Displacement 9 (90%) associates20 used two incisions: one submandibular 20 to
CT post-op 25 mm long and another preauricular 7.0 to 10 mm long.
No displacement 8 (80%) They reported no conspicuous scars. Troulis and Kaban29 used
Displacement 2 (20%) 1.5-cm transfacial Risdon incision, and they had satisfactory
p < 0.001 HS outcome with no complications. In 2002, Schön et al17
presented endoscope-assisted ORIF for subcondylar fractures
in 17 patients. Nine patients were treated with a 4- to 5-cm
rate (39%) in comparison to ORIF (4%).9 After reviewing of submandibular incision and eight patients were treated by

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literature, Haug and Brandt10 determined that “it seems transbuccal approach. They reported nearly 70% overall inci-
rather conclusive that ORIF of the mandibular condyle is dence of perceived some form of scaring. In 2003, Kellman30
superior to closed reduction and MMF.” used an intraoral incision and transcutaneous ports for fixa-
However, the drawbacks of an external approach limited tion. However, one patient required revision, the procedures
its routine use in condylar fractures. The endoscope-assisted were converted to a full-open approach in two patients, and
ORIF is a relatively new technology that allows anatomical four patients were reduced but could not be completed. He
reduction and at the same time has the potential of reducing concluded that this approach is a feasible but challenging
the risk of facial nerve injury, eliminating the need for MMF, technique. In 2003, Miloro used22 a 15- to 20-mm modified
and limiting the problem of scaring.11–15 Risdon incision in six patients. He reported stable occlusions
The used approaches for endoscope-assisted ORIF include with no complications and acceptable scar perception. In
pure transoral, transoral with cheek trocar, or submandibular 2004, Troulis24 reported 4.5% complication rate of temporary
marginal mandibular nerve weakness.
Chen and coworker19 used transbuccal intraoral incision
and transcutaneous ports. They claimed that the transfacial
ports healed inconspicuously but without any details. Martin
and Lee22 used a nearby technique as they used stab incision
immediately over the palpated location of the posterior
aspect of the fracture. This dissection is carried through the
parotid gland and masseter muscle. The sleeved trocar is
inserted and the cheek retractor is mounted on the trocar
sleeve to allow the maintenance of the optical cavity by gentle
traction. The endoscope is placed through the intraoral inci-
sion. Schön et al17 first recommended using intraoral ap-
proach for laterally dislocated condyles whereas external
approach is used for fractures with medial displacement of
the condylar head, condylar fractures with medial override,
and for comminuted condylar fractures. After 5 years of
experience, they recommended using the transoral approach
even for fractures with medial override.1 Moreover, Schön
et al23 stated that the transoral approach is less time con-
suming than the submandibular approach.
Apparently, most of the surgeons tend to use an external
approach or a combined intraoral/external approach for endo-
scope-assisted ORIF with the exception of pure intraoral
Fig. 2 A 60-year-old male patient with an 18-month postoperative
approach by Schön et al.1 The technique presented in this
photo after endoscopic ORIF of subcondylar fracture. It shows excel- work uses an intraoral approach to visualize and reduce the
lent result with nearly nonvisible scar. dislocated segments. As long as the dislocated segments can be

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 Minimizing Submandibular Incision in Endoscopic Subcondylar Fracture Repair Aboelatta et al.

reduced and proper occlusion obtained, the procedure was sufficient to obtain proper reduction and fixation. However,
completed through intraoral incisions in accordance with in many circumstances, a very small submandibular incision
Schön et al.1 Yet, it was difficult to reduce the fractured less than 1 cm is usually needed to achieve good results.
segments appropriately in many circumstances (80% in our Performing the external incision after complete intraoral
study) through intraoral incisions solely. Moreover, mainte- dissection seems very safe to facial nerve and minimizes
nance of the reduced segments is sometimes more difficult scarring markedly. This incision facilitates reduction in rela-
than the reduction itself. In these circumstances, the minimal tively difficult cases and enables visualization of the posterior
submandibular incision served this purpose. It allowed for the border of the mandible clearly.
introduction of an interosseus wires that facilitated both the
reduction and its maintenance till the plate and screws were
applied. This very limited (<1-cm incision) is totally satisfac-
tory for all patients without any annoying apparent scars. References
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