surgical approaches to tmj
TRANSCRIPT
May 2, 2023
1
SURGICAL APPROACHES TO TMJPRESENTATION BY:ADITI RAJVANSHI
May 2, 2023 2
CONTENTS IntroductionAssociated surgical anatomyVarious surgical approaches and their modificationsComplicationsReferences
May 2, 2023 3
Temporomandibular joint and its components frequently require exposure for a myriad of procedures.
May 2, 2023 4
SMAS Concept given by Teisser & defined by Mitz and Peyronie in 1976.
Continuous fibromuscular layer. Synonyms: In scalp – galea aponeurotica In temporal region – temporoparietal fascia, superficial temporal fascia or suprazygomatic SMAS
Below zygomatic arch – parotideomasseteric fascia
May 2, 2023 5
ASSOCIATED NEUROVASCULAR
STRUCTURES
May 2, 2023 6
FACIAL NERVE
DISTANCE FROM THE LOWEST CONCAVITY OF THE EXTERNAL AUDITORY CANAL TO THE BIFURCATION OF
THE MAIN TRUNK OF THE FACIAL NERVE -1.5 TO 2.8 CM.
Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
FROM THE BIFURCATION OF THE FACIAL NERVE TO THE POSTGLENOID TUBERCLE -
2.4 TO 3.5 CM.
Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
THE DISTANCE FROM THE MOST ANTERIOR CONCAVITY OF THE BONY EXTERNAL AUDITORY CANAL TO THE MOST POSTERIOR SIGNIFICANT
TEMPORAL BRANCH OF THE FACIAL NERVE - 0.8 TO 3.5 CM(MEAN 2 CM).
Atlas of temporomandibular joint surgery – Peter D Quinn 2nd ed
May 2, 2023 10
TEMPORAL BRANCHLiebman et al in 1982, described histologically that the layer in which it travels.
They reported that it was locked in the fascial layer between temporalis fascia and subdermal fat superficially.
Stuzin et al in 1988, examined the temporal region by cadaver dissection and reported that it lay within the temporoparietal fascia and travels along undersurface of this fascial layer.
May 2, 2023 11
A straight trajectory A curved trajectory.
Temporal branches of Facial nerve
Ishikawa Y: An anatomical study on the distribution of the temporal branch of the facial nerve.
J Craniomaxillofac Surg 18:287, 1990
May 2, 2023 12
Pitanguy, L, A. S. Ramos: The frontal branch of the facial nerve: The importance of its variation in face lifting. Plast. Reconstr. Surg. 38 (1966) 352
Middelton’s line
May 2, 2023 13
The new guideline for preservation of the entire temporal branch is drawn with a dashed line.
AN ANATOMICAL STUDY OF THE DISTRIBUTION OF TEMPORAL BRANCH OF FACIAL NERVE.
J.CRANIO-MAX-FAC.SURG.18(1990),287-292.
May 2, 2023 14
AN ANATOMICAL STUDY OF THE DISTRIBUTION OF TEMPORAL BRANCH OF FACIAL NERVE.
J.CRANIO-MAX-FAC.SURG.18(1990),287-292.
May 2, 2023 15
Dingman and Grab
Ziarah and Atkinson
MARGINAL MANDIBULAR NERVE
MARGINAL MANDIBULAR
SURGICAL ANATOMY OF MANDIBULAR DISTRIBUTION OF FACIAL NERVE. ZIARAH & ATKINSON, BJOS 1981;19,159-170
MARGINAL MANDIBULAR BRANCH
May 2, 2023 17
Superficial temporal artery
Transverse facial artery
Maxillary artery
SUPERFICIAL TEMPORAL VESSELS
Atlas of human anatomy – Frank H Netter 6th ed
May 2, 2023 18
Auriculotemporalnerve
Auriculotemporalnerve
AURICULOTEMPORAL NERVEArises from posterior part of mandibular division of CN V
Runs beneath lateral pterygoid muscle.
Passes from medial surface of condyle &emerges on to the face behind the TMJ within the superior surface of the parotid gland.
Ascends posterior to the superficial temporal vessels, passes over the posterior root of the zygoma, and divides into superficial temporal branches Atlas of human anatomy – Frank H Netter 6th ed
May 2, 2023 19
RETROMANDIBULAR VEIN
Retromandibular veinAnterior divisionPosterior division
Maxillary veinSuperficial temporal vein
GRAY’S Anatomy, The anatomical basis of clinical practice – 41st ed
May 2, 2023 20
GREATER AURICULAR NERVE
Greater auricular nerve
largest ascending branch of the cervical plexus
arises from the second and third cervical rami, encircles the posterior border of sternocleidomastoid,
perforates the deep fascia and ascends on the muscle beneath platysma
On reaching the parotid gland, it divides into anterior and posterior branches
May 2, 2023 21
SURGICAL APPROACHES
May 2, 2023 22
TYPESExtraoral approaches
1. Preauricular2. Endaural3. Postauricular4. Coronal5. Retromandibular6. Submandibular7. Rhytidectomy
Intraoral approaches1. Intraoral vestibular –
without endoscope with endoscope
May 2, 2023 23
CHOICE OF INCISION
Accessibility to the jointAvoiding damage to vital neurovascular structuresAesthetic concerns on visibility of post op scarsTechnique sensitivity and surgeon’s experienceIn case of ankylosis, choice of interpositioning material.
May 2, 2023 24
PREAURICULAR INCISION
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 25
Incision usually is 3-4cm in length consist of 2 limbs – superior curved limb and inferior vertical limb anterior to tragus.
Initial incision is made through skin and subcutaneous tissues
Incision is outlined at the junction of facial skin and helix of the ear.
May 2, 2023 26Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Dissection
May 2, 2023 27
PREAURICULAR DISSECTION TECHNIQUES DESCRIBEDIN THE LITERATURE…….
- Rowe NL: Surgery of the temporo-mandibular Joint. Proc R Soc Med 65:383, 1972
- Al-Kayat A, Bramley P: A modified pre-auricular approach to the temporomandibular joint and malar arch. Br J Oral Surg 17:91, 1979
Suprafascial procedure
Subfascial procedure
Deep Subfascial Approach - Massimo Politi : J Oral Maxillofac Surg 62:1097-1102, 2004
May 2, 2023 28Politi et al. Deep Subfascial Approach to the TMJ. J Oral Maxillofac Surg 2004
May 2, 2023 29
Incising temporalis fascia
Make an oblique incision parallel to the frontal branch of the facial nerve, through the superficial layer of the temporalis fascia above the zygomatic arch.
Begins at the root of zygomatic arch and extends anterosuperiorly towards upper corner of reflected flap
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 30
Coronal view of dissection to the lateral portion of the zygomatic arch and mandibular condyle region.
Insert the periosteal elevator beneath the superficial layer of the temporalis fascia and strip the periosteum off the lateral zygomatic arch.
May 2, 2023 31Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 32Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Blunt dissection below the zygomatic arch
Exposed TMJ capsule
May 2, 2023 33
First incision is through the upper joint space
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 34Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 35Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 36
SKIN CLOSURE
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 37
MODIFICATIONS OF
PREAURICULAR APPROACH
May 2, 2023 38
Blair’s Inverted Hockey Stick
Dingman’s Incision Endaural Incision
Popowich and Crane Incision Thoma’s Angulated Incision
May 2, 2023 39
AL KAYAT AND BRAMLEY
Skin incision is question mark shaped
Begins antero-superiorly within the hairline & curves backwards and downwards well posterior until it meets upper ear attachment
Incision then follows ear attachment endauraly
A modified pre-auricular approach to the temporomandibular joint and malar archBritish Journal of Oral Surgery 17 (1979-80), 91-103
May 2, 2023 40A modified pre-auricular approach to the temporomandibular joint and malar archBritish Journal of Oral Surgery 17 (1979-80), 91-103
May 2, 2023 41
Advantage:
less bleeding fascial planes can be easily identifiedexcellent visibilitygood cosmetic result
May 2, 2023 42
DINGMAN Incision is started in the fold at the junction of anterior margin of helix
Carried downwards to upper portion of tragus where it is contained inside the margin of tragus to anterior fold of lobule
It again becomes visible at this point and is carried downwards to lower attachment of ear
May 2, 2023 43
ANATOMY
OF EAR
May 2, 2023 44
ENDAURAL APPROACH
First described by Lempart as an approach to mastoid process for surgical improvement of otosclerosis for approaching TMJ
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
May 2, 2023 45
THE ENDAURAL INCISION
Incision begins well within the EAM at superior meatal wall
The incision is carried carefully through the skin over the tragal cartilage at a 90- degree angle to the most convex part of the tragus itself.
The incision is carried superiorly to the uppermost portion of the auricle and then extends in approximately a 45 degree angle into the temporal hairline for about 3 to 4 cm.
May 2, 2023 46
incision is deepened to temporoparietal fascia
continued inferiorly with knife in continuous contact with the tympanic plate
sharp dissection is done along the perichondrium
the flap is raised en masse anteroinferiorly
May 2, 2023 47
Comparison of standard preauricular and endaural surgical approaches
Advantages:
• Most of the vital structures are in a superficial plane.
• Very good access to the joint and also the coronoid process.
• Excellent esthetic result with minimal post operative scar
Disadvantage:• Esthetic compromise if tragal projection is
lost
• Risk of possible perichondritis
May 2, 2023 48
A MODIFIED ENDAURAL APPROACH TO THE TEMPOROMANDIBULAR JOINT
J ORAL MAXILLOFAC SURG 51:33-37,1993
ADVANTAGES:
• Broad based flap with excellent blood supply
• Possibility of residual cartilaginous deformity is less
• Damage to CN VII is unlikely
May 2, 2023 49
May 2, 2023 50
A NEW MODIFIED ENDAURAL APPROACH FOR ACCESS TO THE TEMPOROMANDIBULAR JOINT. BRITISH JOURNAL OF ORAL AND
MAXILLOFACIAL SURGERY (2001) 39, 371–373
May 2, 2023 51
POSTAURICULAR APPROACHDescibed by Alexander & James Incision is placed in the grove between the helix and post auricular skin
Pre-op considerations described by Walter and Geist:
1. History of normal scar formation2. Healthy auditory system with no infection3. No TMJ infection
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
May 2, 2023 52
THE POST-AURICULAR APPROACH FOR GAP ARTHROPLASTY A CLINICAL INVESTIGATIONJOURNAL OF CRANIO-MAXILLO-FACIAL SURGERY 40 (2012) 500-505
3-5cm incision is made parallel & posterior to postauricular flexure
Begins at superior aspect of external pinna and extended till the tip of mastoid process
Dissection is done through posterior auricular muscle to the level of mastoid fascia
May 2, 2023 53
Transected auditory canal closure of auditory canal
Final closure of the incision.
May 2, 2023 54
ADVANTAGES
Predictability of anatomic exposure
excellent surgical exposure of the bilaminar zone and the mandibular condyle posteriorly
Cosmetic superiorityLess risk of CN VII injuryDissection is more rapid
DISADVANTAGES
Not advised in patients susceptible to keloid
InfectionMeatal stenosis can occur
Anterior exposure is limited
May 2, 2023 55
CORONAL APPROACHOR
BICORONAL/HEMICORONAL OR
BITEMPORAL APPROACH
versatile surgical approach to the upper and middle regions of the facial skeleton, including the zygomatic arch and TMJ.
major advantage of this approach is that most of the surgical scar is hidden within the hairline.
May 2, 2023 56
LAYERS OF THE SCALP
ABOVE THE SUPERIOR
TEMPORAL LINE
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 57
LAYERS OF THE SCALP
BELOW THE SUPERIOR
TEMPORAL LINESurgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 58
Incision placement for patients with male pattern hair recession. The incision is stepped posteriorly just above the attachment of the helix of the ear
Incision placement for most female patients.The incision is kept approximately 4 cm behind the hairline
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 59
Scratches, or tattoo dye markings are made across the proposed site of incision.
The first marking is made in the midline and subsequent marks are made laterally at approximately equal distances from the midline.
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 60
The incision is through the skin, subcutaneous tissue, and galea revealing the subgaleal plane of loose areolar connective tissue overlying the pericranium
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 61Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 62
The skin incision below the superior temporal line should
extend to the depth of the glistening superficial layer of the
temporalis fascia,into the subgaleal plane,
continuouswith the dissection above the
superior temporal line.
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 63Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Along the lateral aspect of the skull, the glistening white temporalis fascia becomes visible where it blends with the pericranium at the superior temporal line.
The plane of dissection is just superficial to this thick fascial sheet
May 2, 2023 64Surgical approaches to facial skeleton – Edward Ellis 2nd ed
Near the ear, the flap is dissected inferiorly to the root of the zygomatic arch by incising superficial layer of temporalis fascia
The lateral portion of the flap is dissected inferiorly atop the temporalis fascia
May 2, 2023 65
Exposure of the Temporomandibular Joint:
Access to the TMJ region is gained by dissecting below the zygomatic arch anterior to tragal cartilage.
Masseter is detached from the zygomatic arch exposing the sigmoid notch and TMJ capsule.
Capsule is then incised exposing the TMJ.
May 2, 2023 66
CLOSURE: done in layers
Closure of TMJ capsule is done followed by closure of temporalis fascia .
Superficial layer of the temporalis fascia, which is incised during the approach, is sutured approximately 1 cm superior to the superior edge of the incised fascia.
Galea is closed as a distinct layer.
Scalp incision is closed.
May 2, 2023 67
The coronal incision has been modified.The principal difference involves the position of the skin incision – • placed behind the ear.• use of a zigzag incision instead of a straight incision within
the hairline.AD: further camouflage of the scar
May 2, 2023 68
SUBMANDIBULAR OR
RISDON’SAPPROACH
May 2, 2023 69
Incision usually starts 1.5-2cm inferior to the lower border of mandible.
The initial incision is carried through the skin and subcutaneous tissues to the level of the platysma muscle.Surgical approaches to facial skeleton – Edward Ellis
2nd ed
May 2, 2023 70
Dissection of platysma and exposure of superficial layer of deep cervical fascia
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 71
dissection to the pterygomasseteric muscular sling
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 72
Associated anatomic structuresSurgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 73
dissection is performed through the fascia at the level of the initial skin incision, followed by dissection superiorly to the level of the periosteum of the mandible
May 2, 2023 74
With retraction of the dissected tissues, the inferior border of the mandible is seen.
The pterygomasseteric sling is sharply incised with a scalpel along the inferior border
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 75Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 76
closure is done in multiple layers -
the masseter and medial pterygoid muscles are sutured together
platysma muscle is closed
subcutaneous tissues and skin closure is done
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 77
EXTENDED SUBMANDIBULAR APPROACH
May 2, 2023 78
RETROMANDIBULAR APPROACHOR
HIND’S APPROACH
exposes the entire ramus from behind the posterior border.
therefore may be useful for procedures involving the area on or near the Condylar neck/head, or the ramus itselfSurgical approaches to facial skeleton – Edward Ellis
2nd ed
May 2, 2023 79
ADVANTAGES: close proximity to the condylar area
DISADVANTAGES: passing through the parotid gland tissue, thus increasing the risk of facial nerve injury and salivary fistulae.
May 2, 2023 80
IMPORTANT STRUCTURES
ENCOUNTERED
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 81
DRAPING:
main landmarks should be visible –ear, lower lip and corner of mouth
INCISION:
begins 0.5cm below the ear lobecontinues inferiorly 3-3.5cm just behind the posterior border of mandible.Surgical approaches to facial skeleton – Edward Ellis
2nd ed
May 2, 2023 82Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 83
Blunt dissection
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 84 Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 85Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 86
CLOSURE
Approximating pterygomasseteric sling
Closure of parotid capsule
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 87
TRANSMASSETER APPROACH TOCONDYLAR FRACTURES BY
MINI-RETROMANDIBULAR ACCESSJ ORAL MAXILLOFAC SURG 67:2418-2424, 2009
May 2, 2023 88
ADVANTAGE
1. Smaller scar as access was limited to 2cm only.2. Plane of dissection was superficial to SMAS.3. Risk of Frey’s syndrome, sialocoele and salivary
fistula can be eliminated.4. Surgical site is always perpendicular to fracture site.5. Integrity of joint is always maintained.
May 2, 2023 89
NOVEL RETROMANDIBULARSUBPAROTIDEOMASSETERIC FASCIAL APPROACH FOR
PLACEMENT OF A TEMPOROMANDIBULAR JOINT PROSTHESISJ ORAL MAXILLOFAC SURG 72:1266.E1-1266.E5, 2014
May 2, 2023 92
RHYTIDECTOMY
Also called as facelift approach.Variant of retromandibular, transmasseteric - anteroparotid approach
May 2, 2023 93
LANDMARKS FOR DRAPINGWhen using the rhytidectomy approach, the structures that should be visible in the field include –
1. the corner of the eye,2. the corner of the mouth, and the lower lip
anteriorly, 3. the entire ear and descending hairline, and 2 to 3
cm of hair superior to the posterior hairline, posteriorly
4. the temporal area must also be completely exposed superiorly
May 2, 2023 94
The incision begins approximately 1.5 to 2 cm superior to the zygomatic arch just posterior to the anterior extent of the hairline.The incision then curves posteriorly and inferiorly, blending into a preauricular incision in the natural crease anterior to the pinna.
The incision continues under the earlobe and approximately 3 mm onto the posterior surface of the auricle instead of continuing in the mastoid–ear skin crease.It curves posteriorly toward the hairline and then runs along the hairline, or just inside it, for a few centimeters.
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 95Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 96Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 97Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 98
CLOSURE
Surgical approaches to facial skeleton – Edward Ellis 2nd ed
May 2, 2023 99
TRANSORAL/INTRAORAL ACCESS
May 2, 2023 100Gap arthroplasty for temporomandibular joint ankyloses by transoral approach: A case series
Int. J. Oral Maxillofac Surg
May 2, 2023 101
ENDOSCOPE THROUGH INTRAORAL INCISION
AD: • better visibility• access to high level
fracture using transbuccal trocar.
May 2, 2023 102
Once the capsule has been identified, access to the articular surfaces (superior and inferior joint spaces) can be obtained by a great variety of incisions.
CAPSULAR INCISIONS
May 2, 2023 103;
HORIZONTAL INCISION OVER THE LATERAL RIM OF THE GLENOID FOSSA
The lateral ligament, capsule, and periosteum are reflected inferiorly en masse.
Discal or posterior attachment are dissected sharply with scissors to the level of the condylar neck.
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
May 2, 2023 104
The posterior attachment and disc attachments are then severed sharply at the lateral pole of the condyle from within the developed flap.
These tissues are then reflected superiorly from the head of condyle to expose inferior joint space
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
May 2, 2023 105
HORIZONTAL INCISION BELOWTHE LATERAL RIM OF THE GLENOID FOSSA
The superior joint space is punctured at the level of discocapsular sulcus.
A dissection is then carried inferiorly removing the attachment of the capsule to the disc and exposing the inferior joint space.
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
May 2, 2023 106
HORIZONTAL INCISIONS ABOVE AND BELOW THE
DISC
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
May 2, 2023 107
T-SHAPED INCISION
Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed
May 2, 2023 108
COMPLICATIONS1. Poor facial scar2. Infection3. Wound dehiscence4. Facial nerve palsy5. Perichondritis6. Sialocoele7. Frey’s syndrome
May 2, 2023 109
POOR FACIAL SCAR
May 2, 2023 110
FACIAL NERVE PARALYSIS
May 2, 2023 111
PERICHONDRITIS
SYMPTOMS: pain over auricle and deep in ear canal, edema, erythema, induration
May 2, 2023 112
MANAGEMENT:
1. Conservative: mildest form is treated by using oral and topical antibiotics.
2. Hematoma of the auricle should be drained properly3. If there is any sign of pus drainage – C/S followed by
broad spectrum IV antibiotics.4. In resistant cases, continuous drainage and irrigation
with antibiotics and steroids solution.5. In severe cases, aggressive excision of the necrosed
cartilage involving overlying subcutaneous tissues and skin should be done.
May 2, 2023 113
SIALOCOELE/SALIVARY FISTULA
Sialocoeles result in the accumulation of saliva in glandular/periglandular or subcutaneous tissues.
When the accumulated saliva drain through the skin it is termed as salivary fistula.
May 2, 2023 114
MANAGEMENT
1. Small sialocoeles have said to resolve spontaneously by scar formation which seals the salivary flow.
2. Non surgical management: repeated aspirations and compression dressings administration of anticholinergics antisialogogues
May 2, 2023 115
Surgical management: These procedures direct the salivary flow
into the mouth orDepresses the salivary secretion
1. Creating a tract intraorally2. Duct ligation3. Sectioning of auriculotemporal nerve4. Surgical excision of fistulous tract
May 2, 2023 116
FREY’S SYNDROME
J Oral Maxillolac Surg49:680-682. 1991
named after Dr. Lucia Frey
Frey’s syndrome or gustatory sweating and flushing is characterized by sweating and flushing of the facial skin during meals.
The area involved is on the lateral aspect of the face and upper neck, usually around the parotid region.
May 2, 2023 117
Minor starch iodine test
The distribution of the greater auricular nerve and ATN was painted with a solution containing 3 g iodine, 20 g castor oil, and 200 mL of absolute alcohol.
When dry, the area was lightly dusted with cornstarch.
Given lemon drops to chew for 4 minutes to induce a salivary response.
A positive test occurs when sweat dissolves the starch powder and it reacts with the iodine to produce dark blue spots that may become confluent
May 2, 2023 118
Techniques to evaluate - Blotting paper method Iodine sublimated paper
histogram
Treatment:1. external radiotherapy2. local or systemic application of anticholinergic drugs
Laage-Hellman was the first to apply scopolamine (3% cream) for the treatment of gustatory sweating.3. interposition of a subcutaneous barrier4. injection of botulinum toxin in the involved skin
May 2, 2023 119
Section of some portion of the efferent neural arc
Hemenway [62] in 1960 suggested interrupting the efferent neuronal pathway at the level of the middle ear, by sectioning the tympanic nerve of Jacobson. The first such procedure for gustatory sweating was carried out by Golding-Wood, who named it “tympanic neurectomy
May 2, 2023 120
Surgical Interpositionthe use of a barrier between the facial skin
and the parotid bed.
Botulinum ToxinThe injection of botulinum A toxin in the skin
involved by gustatory sweating was recently proposed by Drobik and Laskawi. It acts by blocking the exocytosis mechanism of the presynaptic terminal, thereby inhibiting release of acetylcholine.
Know your anatomy properly. - Emphasis on Facial .N relation to fascial layers.
Importance of maintaining proper dissection plane.
Chose the appropriate approach based on the problem.
Be aware of the possible complications from each of the approach.
May 2, 2023 122
REFERENCES1. GRAY’S Anatomy, The anatomical basis of clinical practice –
41st ed2. Atlas of human anatomy – Frank H Netter 6th ed3. Peterson’s Principles of Oral and Maxillofacial Surgery – 3rd ed4. Oral and maxillofacial trauma – Fonseca 4th ed5. Surgical approaches to facial skeleton – Edward Ellis 2nd ed6. Atlas of temporomandibular joint surgery – Peter D Quinn 2nd
ed7. Salivary gland disorders - Myers8. An Anatomical Study on the Distribution of the Temporal
Branch of the Facial Nerve - J. Cranio-Max.-Fac. Surg. 18 (1990) 287-292.
9. A modified pre-auricular approach to the temporomandibular joint and malar arch - British Journal of Oral Surgery 17 (1979-80), 91-103.
10.The surgical anatomy of the mandibular distribution of the facial nerve British Journal of Oral Surgery (1981) 19, 159-l 70.
May 2, 2023 123
A Modified Endaural Approach to the Temporomandibular JointOral Maxillofac Surge 51:33-37,1993.
A new modified endaural approach for access to the temporomandibular joint British Journal of Oral and Maxillofacial Surgery (2001) 39, 371–373.
The Deep Subfascial Approach to the Temporomandibular Joint - J Oral Maxillofac Surg 62:1097-1102, 2004.
Ankylosis of temporomandibular joint - Dingman A truly endaural approach to the temporo-mandibular joint - British
Journal of Plastic Surgery (1984) 37,65-68. Transmasseter Approach to Condylar Fractures by Mini-Retromandibular Access - J Oral Maxillofac Surg 67:2418-2424, 2009
Modified Preauricular Approach and Rigid Internal Fixation for Intracapsular Condyle Fracture of the Mandible - J Oral Maxillofac Surg 68:1578-1584, 2010.
The post-auricular approach for gap arthroplasty e A clinical investigation -Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 500-505.