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Treatment of Mandibular Angle Fractures Using the Modified Risdon Approach

Domergue, Sophie M.D.; El Najjar, Fouad M.D.; Frison, Laure M.D.; Yachouh, Jacques M.D., Ph.D.

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Plastic and Reconstructive Surgery: April 2012 - Volume 129 - Issue 4 - p 748e-749e
doi: 10.1097/PRS.0b013e318245e88c
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Sir:

Figure
Figure

No consensus has been reached on the surgical approach for treatment of mandibular angle fractures. The most common approaches are the inferior vestibular approach1 and the Risdon approach.2 The modified Risdon approach described in 2006 by Meyer et al.3 for fixation of subcondylar mandibular fractures can also be used for fixation of mandibular angle fractures with displacement.

This approach requires a 4-cm incision along the basilar border of the mandible. A 1-cm subcutaneous lift is performed around the wound on the superficial surface of the platysma muscle. The platysma muscle is then incised along the same axis to expose the masseter muscle. This one is sectioned at its insertion on the basilar border of the mandible at the same level as the incision of the platysma muscle. Care is taken to avoid the marginal mandibular branch or the buccal branch of the facial nerve, running under the masseter aponeurosis. Cutaneous laxity in this area provides better exposure of the fracture by moving the incision backward and frontward. The facial pedicle can be ligated to access the anterior part of the corpus. Anatomical reduction of the fracture is then easy. The whole external surface of the mandible is exposed, thereby avoiding excessive traction of soft tissues and facilitating plate positioning on the external oblique line. The second plate can be positioned very low on the basilar border (Fig. 1). Bone scaling can also be performed to improve plate positioning.

Fig. 1
Fig. 1:
Fixation with a single monocortical miniplate on the lateral surface of the external oblique line and a more rigid bicortical plate on the basilar border.

In a clinical trial, Mehra and Murad4 compared treatment of isolated angle fractures with an intraoral miniplate fixation on the oblique line versus a rigid plate on the basilar border with the modified Risdon approach. Fracture reduction was found to be better with the Risdon approach on control radiographs.

Better laxity combined with improved access to the branches of the facial nerves decreases the risk of nerve damage. In their analysis of 75 subcondylar fractures treated with the modified Risdon approach, Meyer et al.3 reported no postoperative nerve complications.

With this approach, the absence of communication between the fracture site and the buccal cavity limits the risk of postoperative infection. Furthermore, the absence of a mucosal incision reduces the risks of subsequent long-term exposure of the alveolar plate. In their series, Mehra and Murad4 reported exposure of the alveolar plate in 4 percent and delayed intraoral healing in 5.1 percent of patients operated on with the intraoral approach.

With the modified Risdon approach, the scar is barely visible between the area exposed to light and the darker cervical area in the shadow of the face (Fig. 2). The intraoral approach is therefore recommended for any patients with a risk of hypertrophic scars.

Fig. 2
Fig. 2:
The scar 18 months after surgery.

The modified Risdon approach has many advantages for the fixation of mandibular angle fractures. We believe it is also indicated for comminuted fractures, or when a bone graft must be associated to improve healing. In children, dark-skinned patients, or patients with a history of poor wound healing, the intraoral approach remains the criterion standard.

Sophie Domergue, M.D.

Fouad El Najjar, M.D.

Laure Frison, M.D.

Jacques Yachouh, M.D., Ph.D.

Oral and Maxillofacial and Plastic Surgery Department, Lapeyronie Hospital, Montpellier, France

REFERENCES

1. Barthélémy I, Boutault F, Paoli JR, Dodard L, Gasquet F, Fabié M. Treatment of fractures of the mandibular angle using miniplates attached through the transjugal approach (in French). Rev Stomatol Chir Maxillofac. 1996;97:84–88.
2. Risdon F. Ankylosis of temporomaxillary joint. Oral Surg. 1934;1933–1936.
3. Meyer C, Zink S, Wilk A. Modified Risdon approach for the treatment of subcondylar fractures of the mandible (in French). Rev Stomatol Chir Maxillofac. 2006;107:449–454.
4. Mehra P, Murad H. Internal fixation of mandibular angle fractures: A comparison of 2 techniques. J Oral Maxillofac Surg. 2008;66:2254–2260.

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