Authors of section

Authors

Nicolas Homsi, Paulo Rodrigues, Gregorio Sánchez Aniceto, Beat Hammer, Scott Bartlett

Executive Editors

Edward Ellis III, Eduardo Rodriguez

General Editor

Daniel Buchbinder

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Submental approach

1. Principles

The submental approach is used to treat fractures of the anterior mandibular body and symphysis. These fractures can usually be approached and treated intraorally. However, depending on the difficulty or severity of the fracture, and/or the presence of a laceration suitable, an extraoral approach via the submental route may be indicated.

An advantage to this approach is that the surgeon can easily inspect the lingual surface of the mandible to assure optimal reduction of the fracture in this region.
There are no major neurovascular structures in the submental area.

submental approach

Variations in incision:
A) Following curvature of anterior mandible
B) Hidden in submental skin crease

According to the anatomy and surgical preference, both techniques offer adequate access to this area.

Variations in incision

2. Skin incision

General consideration
Use of a solution containing vasoconstrictors ensures hemostasis at the surgical site. The two options currently available are the use of local anesthetic or a physiologic solution with vasoconstrictor alone.

Skin incision
Incise the skin along the path selected.

Incise the skin along the chosen path

3. Dissection

Carry the incision through the skin and subcutaneous tissues to the platysma muscle.
The platysma muscle must be divided.

There may be a natural separation of the muscle in the midline region. Additionally the platysma muscle can become very thin in this region.

Soft-tissue laceration

Dissection is carried out to the inferior border of the mandible. The periosteum is incised sharply and the flap is elevated to expose the anterior surface of the symphysis.

submental approach

4. Wound closure

The wound is closed in layers to realign the anatomic structures and to eliminate dead space.

The periosteum and platysma muscle should be closed in different layers.

A variety of skin closure techniques are available according to surgical preference.

The wound is closed in layers to realign the anatomic structures

5. Option: bilateral extension

Submental extension
The submental incision can be extended laterally to encompass both the right and left mandible by degloving the entire lateral surface of the mandible in the same way as in the submandibular approach. Click here for a detailed description of the submandibular approach.
This may be necessary in complex fractures such as comminuted, atrophic, and severe bilateral fractures.

An extension of the incision parallel to the inferior border is shown in the following illustrations as the approach is explained.

submental approach

To approach complex mandibular fractures the surgeon essentially combines a right and left submandibular incision with a submental one.

The inferior border of the mandible is marked along with the planned skin incision.

The inferior border of the mandible is marked along with the planned skin incision

Clinical image of an exposed edentulous atrophic fractured mandible.

Exposed edentulous atrophic fractured mandible