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Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 500e505

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Journal of Cranio-Maxillo-Facial Surgery

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The post-auricular approach for gap arthroplasty e A clinical investigation

Vishal Bansal*, Sanjeev Kumar, Apoorva Mowar, Anurag Yadav, Gagan KhareDepartment of Oral & Maxillofacial Surgery, (Head of Department: Dr. Sanjeev Kumar), (Head of Institution: Dr. N.K. Ahuja), Subharti Dental College, Subhartipuram,Delhi e Haridwar Meerut By Pass Road, Meerut, Uttar Pradesh 250002, India

a r t i c l e i n f o

Article history:Paper received 2 September 2010Accepted 24 August 2011

Keywords:Temporomandibular jointAnkylosisPosterior auricular approachPre-auricular approach

* Corresponding author. Tel.: þ91 9837233950; faxE-mail address: drbansalvishal@rediffmail.com (V

1010-5182/$ e see front matter � 2011 European Assdoi:10.1016/j.jcms.2011.08.009

a b s t r a c t

Objective of this prospective study was to evaluate and compare posterior auricular approach for surgeryof temporomandibular joint ankylosis with preauricular approach. These evaluations were done on thebasis of certain parameters like incidences of facial nerve injury, time taken to expose ankylotic mass,haemorrhage and quality of exposure of joint and surrounding structures. This study was conductedamong 15 patients of temporomandibular joint ankylosis. A total number of 30 joints were operated.These joints were divided in two groups i.e. Group A e preauricular group, Group B e postauriculargroup. Fifteen joints were operated in each group. Age of patients was in range of 4e65 years. All thepatients were operated under general anesthesia. Preoperative, intraoperative and postoperative eval-uations were done according to parameters. Patients were recalled up to 3 months for observations.Results have shown that in postauricular group incidences of facial nerve injury was significantly less,more time was taken to expose the ankylotic mass, incidences of haemorrhage was more and exposure ofstructures anterior to joint was difficult. Whereas preauricular approach is less time consuming, inci-dence of facial nerve damage is higher, exposure of structures anterior to joint is good and intraoperativeincidences of haemorrhage is less.

� 2011 European Association for Cranio-Maxillo-Facial Surgery.

1. Introduction

Temporomandibular joint (TMJ) ankylosis is still a cause ofmajor concern in the Indian subcontinent. Most cases are due totrauma in early childhood; other less common causes being earinfection and forceps delivery. Except for early cases of fibrousankylosis, which can be treated using Brisement forces, all othercases of ankylosis require surgical intervention. These treatmentscan vary from simple resection of the bony fusion to recon-struction of the joint with foreign or autologous materials(Gundlach, 2010). This author describes 40 patients of trueankylosis treated surgically over the last 30 years by applyinginterposing silastic sheeting or by implanting a metal TMJprosthesis.

In the Indian subcontinent, an effective treatment for TMJankylosis is gap arthroplasty without interpositioning followed byvigorous physiotherapy (Roychoudhury et al., 1999). Direct accessto the temporomandibular joint, malar arch and condylar neck iscompromised by the close proximity of major named vessels, trunkand branches of facial nerve and parotid gland. It is therefore notsurprising that historically many different approaches have been

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described by various surgeons which all aim to provide safeadequate access with acceptable aesthetic results.

Several extraoral methods of exposing the joint are practicedbut the most popular are the pre-auricular (Ruiz and Guerrero,2001) and its modifications the submandibular and retro-mandibular approaches (Dias, 1984, Kreutziger, 1984a). Significantpotential complications, such as facial nerve paresis, paresthesia ofauriculotemporal nerve, Frey’s syndrome, intra-operative and post-operative haemorrhage, excessive scar formation, occasionalanatomic deformity of the ear, surgical infection, salivary fistulaand sialocele have been reported.

Otolaryngologist have been using the posterior auricularapproach for middle ear surgery for a long time, but it was Bock-enheimer who first used this method for temporomandibular jointankylosis (Bockenheimer, 1920). Since his original report, othershave refined the technique significantly in order to improve theoutcome (Kreutziger, 1987). In spite of the obvious advantages ofthe post-auricular approach; it has not become popular with oraland maxillofacial surgeons probably because of unfamiliarity withpost-auricular anatomy, the potential of damaging the auditorycanal and doubts regarding ease of surgery.

This study was designed to assess the advantages, if any, of thepost-auricular approach over the pre-auricular in patients withbilateral ankylosis, in all of whom gap arthroplasty was beingperformed.

Surgery.

Fig. 1. Marking of the incision.

Fig. 2. Exposure of the temporalis fascia.

Fig. 3. Transected auditory canal.

V. Bansal et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 500e505 501

2. Material and methods

A total of 30 temporomandibular joints in 15 patients who hadbeen operated on were included in this study. Half the joints wereaccessed through the Al-Kayat & Bramley’s pre-auricular method(Kreutziger, 1984a) while the post-auricular approach (Bramley,1990) was used in the remaining half. All patients were operatedby the same surgeon.

Patients with any of the following conditions were excludedfrom the study:

1. Haemoglobin less than 10 gm%.2. Pre-existing parotid swelling or abscess.3. Pre-existing otitis media or externa, congenital or develop-

mental stenosis of the external auditory canal or conductive orsensory deficit in hearing mechanism.

4. TMJ ankylosis secondary to ear infection or due to anypathology.

5. TMJ inflammatory disease of joint e.g. juvenile arthritis orrheumatoid arthritis.

The following parameters were recorded for each joint for thepurpose of this study.

1. Time taken from incision to exposure of the ankylosed joint.2. Measurement of intra-operative haemorrhage was obtained by

noting the total collection in suction reservoir minus the salineused for irrigation added to the weight of blood soaked gauze.Each milligram increase in weight from preoperative weightwas taken as 1 ml of blood.

3. Post-operative function of facial nerve for temporal & zygo-matic branches was evaluated by the HouseeBrackmann facialnerve grading system (Vasconcelos et al., 2007).

4. Post-operative anatomic deformity/stenosis of external audi-tory canal was clinically assessed by an ENT surgeon.

5. Post-operative hearing defect, if any was assessed by audiom-etry and impedance tympanometry.

6. The patient’s satisfaction with the post-operative scar wasnoted regarding its visibility, as perceived by the patient andtheir relatives.

The post-auricular technique: (Bramley 1990).Following antiseptic preparation of the peri-auricular skin,

pinna and ear canal, a gauze pellet is carefully placed into theexternal auditory canal to exclude blood spillage. Marking of theincision is done 3e4 mm behind the pinna following the line ofauricular flexure (Fig. 1) and the post-auricular skin is generouslyinfiltrated with epinephrine (1:100,000).

The incision is made upto the first anatomical landmark, themastoid fascia, which is contiguous with the superficial layer of thetemporalis fascia (Fig. 2). This fascial layer is exposed by bluntdissection about 1.5 cm anterior to the auditory canal. Staying onthe mastoid fascia the superior and posterior circumference of theexternal auditory canal is developed. This is done very gently as theposterior wall of the canal does not contain any cartilage. A tunnelof subcutaneous tissue below the canal is created by blunt dissec-tion, levelled to the transition area of the pinna and the auditorycanal, where it is cleanly sectionedwith a No.11 BP blade in a singlemotion (Fig. 3). Inferiorly, the posterior edge of the parotid gland, ifencountered, is freed and turned forward. The skin flap thusdeveloped, is bluntly dissected anteriorly to further expose thetemporalis fascia, the second anatomical landmark, over thetemporal region.

An extended Al-Kayat and Bramley type incision is given on theexternal layer of temporalis fascia, which is carried down through

V. Bansal et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 500e505502

the periosteum to the zygomatic arch. A tissue flap containing theperiosteum, overlying connective tissue, superficial layer of tem-poralis fascia and frontal ramus of facial nerve is elevated anteriorlyfrom the zygomatic arch along with the skin flap. The joint capsuleis identified next and incised to expose the ankylotic mass.

A gap arthroplasty is then performed and interincisal openingchecked. If the interincisal opening is still inadequate, the Kaban’sprotocol is followed until satisfactory mouth opening is achieved.

The superficial temporalis fascia and muscle is sutured withresorbable 3-0 suture followed by meticulous closure of the audi-tory canal (Fig. 4). The pinna is placed in its anatomic position andsutured back by some additional subcutaneous and skin suturing(Fig. 5).

All patients were given a single dose of corticosteroid, dexa-methasone at a dose of 0.4 mg/kg/day I.V., 1 h prior to the surgeryand then post-operatively four doses at an interval of 6 h to reduceswelling. All patients were given antibiotics, (3rd generationCephalosporin, Cefotaxim, at a dose of 50 mg/kg/day) in twodivided doses until the 3rd post-operative day in cases of pre-auricular approach and until 5th post-operative day in cases ofthe post-auricular approach as the external auditory canal maycontain some potentially pathogenic bacteria. Metronidazole wasalso administered I.V. for the same duration at a dose of

Fig. 4. Meticulous closure of auditory canal.

Fig. 5. Final closure of the incision.

15e18 mg/kg/day in three divided doses. All patients were movedto oral antibiotics after discharge from hospital for the next 3 days,except for patients who developed infection who were kept on I.V.antibiotics for three more days.

Patients operated via the post-auricular approach were given anear pack of topical antibiotic ointment soaked gauze for 3 dayswhichwas changed every day and irrigationwith normal saline andMetronidazole was started after 2nd post-operative week asdescribed by (Bramley 1990). In post-auricular patients a smallstent was made by cutting the rounded side of rubber catheterapproximately 2e3 cm in length. The rounded part of the catheterwas inserted into the external auditory canal after coating andfilling the hollow of the catheter with Soframycin. The stent waskept in place for 7 days and removal and reinsertion after irrigationwere done every alternate day.

Post-operative analgesia was obtained by I.M. injection ofDiclofenac sodium (Voveran) administered at a dose of 2e3 mg/kg/day in three divided doses for 3 days. However for patients belowthe age of 12 years rectal suppository of Diclofenac sodium wasadministered at a dose of 2e3 mg/kg/day in three divided doses for3 days. All patients were moved to oral analgesics after 3rd post-operative day.

3. Results

The results of this prospective study conducted on 30 tempo-romandibular joints, of which 15 were operated on via a pre-auricular approach and 15 via a post-auricular approach weretabulated. The result of various variables observed is as follows:

1. Measurement of intra-operative blood loss: average intra-operative haemorrhage measured in 15 temporomandibularjoint surgeries via the pre-auricular approach was245.7 ml/joint, whereas for the 15 temporomandibular jointsurgeries done via the post-auricular approach was339.8 ml/joint. In case of post-auricular approach averageintra-operative haemorrhage was found to be more by94.1 ml/joint than pre-auricular approach (Graph 1).

2. Time taken to expose the ankylotic joint: average time takenfrom the start of skin incision to exposure of the ankylotic jointwas 15.78 min/joint for the pre-auricular approach and23.71 min for the post-auricular approach. Post-auricularapproach on an average took 7.93 min/joint more time forexposure (Graph 2).

3. Stenosis of external auditory canal after surgery: temporarystenosis was noted in 60.0% of the post-auricular approachcases while it occurred in 6.67% cases of the pre-auriculargroup (Graph 3).

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V. Bansal et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 500e505 503

4. Temporal branch weakness: transient temporal nerve weak-ness occurred in 46.67% joints operated by the pre-auricularapproach and 13.33% in the post-auricular approach (Graph 4).

5. Zygomatic branch weakness: transient zygomatic nerveweakness was observed in 26.67% cases and 0% cases for pre-auricular and post-auricular approaches respectively (Graph 5).

6. Hearing loss: mild hearing loss was observed in 13.33% cases inthe pre-auricular approach. For the post-auricular approachmild hearing loss was observed in 46.67% cases. All patientsrecovered completely within 2 months (Graph 6).

7. Aesthetic scar/visibility of scar: all patients reported satisfac-tion with post-auricular approach while on the side of pre-auricular approach they reported 100% visibility (Graph 7).

Graph 6.

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Post-operative Scar Visibility (% Incidence)

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Graph 7.

4. Discussion

The pre-auricular approach has been used for decades fortemporomandibular joint surgery and its various advantages anddisadvantages are well known and accepted. In this study, theevaluation of results of post-auricular approach was thus based onparameters established by the pre-auricular approach.

In our study, the post-auricular approach bled significantlymorethan the pre-auricular approach. However local measures likepressure pack, ligation of large vessels, cauterization of smallvessels, pressure pack, direct application of Feracrylum 1% solution(Uniheal) was sufficient to arrest intra-operative haemorrhage in allthe cases. We attribute the excessive bleeding to unfamiliarity ofthe approach in our initial cases. Also the extended duration ofsurgery and more vascular encounters in the post-auricularapproach contributed to intra-operative haemorrhage.

V. Bansal et al. / Journal of Cranio-Maxillo-Facial Surgery 40 (2012) 500e505504

The time taken for exposing the temporomandibular joint wasalso more via the post-auricular approach as more anatomicstructures were encountered during exposure of the temporo-mandibular joint, e.g. the external auditory canal. Additionally,careful reflection of the flap to expose mastoid fascia and tempo-ralis fascia as well as development of a circumference around thecanal to ensure adequate tissue for accurate suturing took addi-tional time.

Weakness of facial nerve is a major concern in temporoman-dibular joint surgery as branches of this nerve are encountered inthe region of surgery (Vasconcelos et al., 2007). Keith L. Kreutzigersreported less incidence of facial nerve damage while performingthe surgery via post-auricular approach (Kreutziger, 1984a). In ourstudy, the incidence of facial nerve damage was significantly higherin cases in he pre-auricular group as compared with the post-auricular group. No permanent damage to nerve branchesoccurred in either group as all cases recovered within 3 monthspost-operatively.

Infection is one of the complications of temporomandibularsurgery irrespective of the approach (Alexander and James, 1975).Infection control was done by strict asepsis intra-operatively andpost-operatively and use of antibiotics i.e. 3rd generation Cepha-losporins and Metronidazole for 3 days in the pre-auricular groupand for 5 days in the post-auricular group as external auditory canalmay contain some potentially pathogenic bacteria. Development ofinfection was observed mainly in cases where haematoma haddeveloped.

Alexander & James reported the possibility of stenosis in surgerywhen using the post-auricular approach (Alexander and James,1975) and in our study stenosis of the canal was evident chiefly incases operated on via the post-auricular approach. As the posteriorpart of the canal does not have cartilage and is very delicate itsperforation can lead to post-operative infection, stenosis, anatomicdeformity or hearing impairment. Axhausen has reported thatmostof these complications can be avoided bymeticulous suturing of theexternal auditory canal (Axhausen, 1931).

Stenosis was significantly higher in cases operated on via thepost-auricular approach, with 60% cases of stenosis in the post-auricular group and only 6.67% cases of stenosis in the pre-auricular group. Stenosis of external auditory canal is a majorcomplication of the post-auricular approach (Dolowick andKretzschmar, 1982, Kreutziger, 1984a), which can be the sequel ofinfection or due to improper suturing of external auditory canal,any perforation of canal or damage to the cartilage. To preventstenosis a rubber stent was kept in the external auditory canal for7 days. The width of the stent is an important factor as it should fitin the external auditory canal to engage the walls and apply pres-sure on the walls to prevent stenosis. A stent was found to be aneffective method of preventing stenosis. Ninety percentage of thestenosis were false stenosis and were inflammatory in origin. Allpatients recovered within 45 days except one who was advised tohave a canaloplasty. Transient hearing loss of mild degree wasobserved in both the approaches with a statistically significantdifference, however all cases recovered within 2 months. Loss ofhearing was not associated with any sensory disturbances butfound to be the conduction defect which was confirmed by audi-ometry 1 month post-operatively.

Exposure of the joint and its surrounding structures is animportant measure for the comparison of the two approaches.Good exposure and visualization of the posterior aspect of themandibular condyle, the lateral pole of the condylar head isobtained via a post-auricular approach. Placement of retractor toprotect the maxillary artery is also easier in a post-auricularapproach, however anterior visualization, approach to the coro-noid process and sigmoid notch was not as good as with

pre-auricular incision until the incisionwasmodified to extend intothe temporal region. Posterior exposure of the condylar head withthe pre-auricular approach was not as good as with the post-auricular approach. However with the pre-auricular approachtherewas excellent exposure of the sigmoid notch and the coronoidprocess of the mandible facilitating coronoidectomy in cases wherethe ankylotic mass had involved these structures.

The pre-auricular incision resulted in a scar in the pre-auriculararea and was pointed out by all patients as being visible and thusless desirable. The post-auricular incision was well hidden fromview and was considered most acceptable by the patients as well astheir relatives.

In this study, comparison of the two techniques revealed thatthe post-auricular approach allows adequate exposure witha decreased occurrence of injury to the facial nerve (Kreutziger,1984b) and excellent cosmetic results (Walters and Giest, 1983).

Facial nerve paresis is a significant risk when using the pre-auricular approach. However, when considering the possibility ofhaemorrhage, external auditory canal stenosis, damage to thecartilaginous framework of external auditory canal, deformity ofauricle; all potential complications of the post-auricular approach;the pre-auricular approach should still be considered as theapproach of choice. For cosmetically conscious individuals or thosepatients who have greater than normal potential for scarring, thepost-auricular approach is a good alternative.

5. Conclusion

Clinical as well as statistical analysis of this study revealssignificant over all difference between the two approaches. On thebasis of the results of this study, both the pre-auricular as well asthe post-auricular approach are appropriate for gap arthroplastyprocedures for the release of ankylosis of temporomandibular joint.The post-auricular approach has certain advantages but thisapproach does not provide adequate access to the coronoid processand sigmoid notch as compared to the pre-auricular approach.Therefore a post-auricular approach should be preferred in cases ofankylosis within joint capsule, whereas a pre-auricular approachproduces adequate exposure and is advantageous in surgery forcases of large ankylotic masses but scarring and facial nervedamage are potential drawbacks. Therefore one must evaluate andweigh the risks and drawbacks of both the approaches and a deci-sion should be based on the type of ankylosis, surgeon choice andpatients aesthetic demand.

From our experience using the pre-auricular approach it isassociated with reduced haemorrhage, better exposure of thecoronoid process and sigmoid notch can be achieved and it is lesstime consuming than the post-auricular approach. It has disad-vantages such facial nerve injury, visible scaring and increasedpost-operative swelling.

Sources of support in the form of grants

None.

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