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The submandibular approach was described by Risdon in 1934.
41,42
y
y
Make the incision 2 centimeters (cm) below the angle of the man-
dible in a natural skin crease.
43
y
y
Dissect through skin, subcutaneous fat, and superficial cervical fascia
to expose platysma muscle.
y
y
Dissect the platysma, identify the superficial layer of the deep
cervical fascia. The marginal mandibular nerve is deep to this layer.
44
y
y
Dissect through deep cervical fascia with the aid of a nerve stimula-
tor/monitor to the mandibular bone.
y
y
Dissect down to the level of the pterygomassitric sling, dividing it to
expose bone.
d. Retromandibular Approach
The retromandibular approach was described by Hinds in 1958.
45,46
y
y
Make a vertical incision 0.5 cm below the lobe of the ear, and con-
tinue it inferiorly 3.0–3.5 cm. It should be behind the posterior
mandibular boarder and should extend to the level of the angle.
y
y
Dissect through the platysma and superficial musculoaponeurotic
layer and parotid capsule.
y
y
Consider using the aid of a nerve stimulator or facial nerve monitor,
as the marginal mandibular branch and the cervical branch of the
facial nerve may be encountered here.
y
y
The retromandibular vein runs vertically in the parotid and should
be identified and ligated or retracted to gain access to the lateral
mandible.
y
y
Sharply incise the pterygomasseteric sling and elevate the muscle off
the lateral surface of the mandible superiorly. This will give access to
the ramus and subcondylar region of the mandible.
e. Preauricular Approach
The preauricular approach is excellent for exposure to the TMJ.
47,48
y
y
Make the incision in the preauricular fold 2.5–3.5 cm in length, as
described by Thoma
48
and Rowe.
49
Take care not to extend the
incision inferiorly, since it may encounter the facial nerve as it enters
the posterior border of the parotid gland.
y
y
Carry the incision and dissection along the lateral perichondrium of
the tragal cartilage.
y
y
Superiorly, if the temporal fascia is encountered, the dissection
should be carried deep through the superficial temporal fascia or the
temporoparietal fascia. The aid of a nerve stimulator or facial nerve
monitor should be considered if the dissection approaches the orbital
or frontal branch of the facial nerve.