Authors of section

Authors

Ricardo Cienfuegos, Carl-Peter Cornelius, Edward Ellis III, George Kushner

Executive Editors

Marcelo Figari, Gregorio Sánchez Aniceto

General Editor

Daniel Buchbinder

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Intraoral approach to the angle

1. Principles

Vestibular incisions
The intraoral approach is used for the majority of simple angle fractures.
Depending on whether or not a third molar is to be extracted (Click here for more information on teeth in the line of the fracture), there are two surgical approaches. Where there is no third molar present, or where one is present but is to be left in place, a purely vestibular incision approximately 5 mm away from the attached gingiva is made (A). When an erupted third molar is to be removed, the incision must incorporate the attached gingiva around the buccal side of the tooth (B, combination of vestibular and envelope incisions).

Oral contamination is not a contraindication for an intraoral incision.

Restricted access and contamination
In complex fractures including comminuted, edentulous, and avulsive fractures that will require the placement of load-bearing reconstruction plates, a transfacial/extraoral approach can provide better access to treat the injury.

The two surgical approaches: A: Without third molar present, B: third molar is to be removed

Sensory buccal nerve
The sensory buccal nerve crosses the upper anterior rim of the mandibular ascending ramus in the region of the coronoid notch. It is usually below the mucosa running above the temporalis muscle fibers. When the posterior vestibular incision is carried sharply along the bony rim, the buccal nerve is at risk of transsection, followed by numbness in the buccal mucosal region. Therefore, to protect the nerve, the posterior dissection is to be extended bluntly as soon as the lower coronoid notch is reached.

Protecting the nerve

The photograph shows the sensory buccal nerve.

intraoral approach to the angle

Buccinator muscle
The lateral mucogingival vestibular incision transsects the lower attachment of the buccinator muscle. Stripping the mucoperiosteal flap laterally dislocates the lower border of the muscle. To reattach the muscle, the sutures for wound closure in the lateral vestibular should not only be superficial. The suture should catch all layers (mucosa and muscle) as a safeguard for muscle reattachment.

The suture should catch all layers

2. Vestibular incision

Unless contraindicated, infiltrate the area with a local anesthetic containing a vasoconstrictor.
Make an incision through the mucosa in the vestibule approximately 5 mm away from the attached gingiva (in the mucogingival junction), extending up the external oblique ridge.

The fracture must be reduced adequately before fixation is applied. The fixation can be either by transbuccal or right-angled instrumentation.

Make an incision through the mucosa in the vestibule

3. Exposure

This clinical image shows the fracture exposed, reduced, and MMF secured.

This clinical image shows the fracture exposed, reduced, and MMF secured

4. Combination with the transbuccal technique

The transbuccal trocar may also assist the surgeon in positioning posterior and inferior screws, sometimes avoiding the need for an extraoral approach.

Click here for a detailed description of the transbuccal technique.

The transbuccal trocar may also assist the surgeon in positioning posterior and inferior screws

5. Wound closure of the vestibular incision

After thoroughly irrigating the wound and checking for hemostasis the surgeon can close the incision.

Closing the incision

6. Wound closure

Surgical dressing
An elastic pressure dressing covering the angle region helps support the soft tissues and prevent hematoma formation.

Placing of an elastic pressure dressing

7. Wound closure using envelope flap

The envelope portion of the flap is undermined with scissors to facilitate tension-free advancement over extraction site. Generally, resorbable sutures are used for this closure.

The envelope portion of the flap is undermined with scissors

The flap is advanced and closed over the extraction site.

The flap is advanced and closed over the extraction site