High Submandibular Anteroparotid Approach for Open Reduction and Internal Fixation of Condylar Fracture

Figure 3

(a) Black arrow: facial artery; black triangle: sternocleidomastoid muscle. The skin incision line, the outline of the mandible, the sternocleidomastoid muscle, and the facial artery are traced using gentian violet. The planned skin incision is 0.5 mm caudally from the mandibular margin and 5 to 7 mm posteriorly from the posterior margin of the ramus to include the mandibular angle. An incision line with a total length of approximately 5 cm is made. (b) Black dotted line: platysma incision line; black square: masseter muscle. The platysma fascia is incised, approximately 2 cm subcutaneously, and the flap is raised. Once the platysma is located, it is incised to the depth of the masseter fascia such that the incision is 1 cm cranial from the mandibular margin in the anterior direction and 2 cm cranial from the mandibular margin in the posterior direction. In women, the platysma is thin, and the masseter fascia lies immediately inside the platysma. (c) A reverse warping muscle retractor is applied to the posterior margin of the ramus to gently extrude the parotid gland backward, and the masseter muscle is pulled slightly forward with the muscle retractor to expand the operative field. The periosteum is delaminated from the posterior margin of the ramus using a raspatorium, and the fracture site is located. A 0.5-mm-diameter metal wire for pulling the mandibular ramus is passed through caudally to approximately 2 cm of the fracture line. (d) By pulling the metal wire downward, the ramus is pulled sufficiently downward, and reduction is achieved. (e) After reduction, the fragment is fixed using a MatrixMANDIBLE Subcondylar Strut Plate.

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