Risk factors for postoperative facial nerve injury in retromandibular-approach surgery: A retrospective study including CT measurements of maxillofacial bone structure.

The purpose of this retrospective study was to identify risks of postoperative facial nerve injury (FNI) in mandibular condylar fractures. A total of 59 consecutive cases of condyle fracture or plate removal with a retromandibular transparotid approach (RMTA) were divided into FNI and non-FNI groups that were evaluated for associations with age, sex, laterality, fracture type, height, weight, body mass index (BMI), and maxillofacial bone height and width diameters on computed tomography (CT). FNI occurred in 11 of 59 patients (18.64%), all of them female (p = 0.0011). Other statistically significant factors on univariate analysis for FNI included a short height (156.95 ± 8.16 cm vs. 164.29 ± 9.89 cm, p = 0.04), low weight (46.08 ± 8.03 kg vs. 58.94 ± 11.79 kg, p = 0.003), low BMI (18.64 ± 2.63 kg/m2 21.68 ± 3.02 kg/m2, p = 0.007), short condylion-anterior fracture distance (19.34 ± 3.15 mm vs. 22.26 ± 3.96 mm, p = 0.04) and short condylion-posterior fracture distance (20.12 ± 3.98 mm vs. 25.45 ± 5.02 mm, p = 0.009). Our retrospective study suggested that FNI with RMTA surgery occurs particularly in female patients and may occur more frequently in patients who are short, lean or have high condyle fractures.

Patient's Perception of Outcome after Extracapsular Fractures of the Mandibular Condyle Differs from Objective Evaluation-Experience of a Third-Level Hospital.

Background: The aim of this study is to assess patients' subjective perception of treatment outcome after extracapsular fractures of the mandibular condyle. Methods: A questionnaire survey regarding facial nerve palsy (FNP), malocclusion, pain, reduction in maximum mouth opening (MMO) and further discomfort after 3, 6, and 12 months was carried out. Patients aged 18 or more presenting with an extracapsular condylar fracture between 2006 and 2020 were identified by purposive sampling Questionnaires were received from 115 patients. Fractures were classified on the basis of the pre-treatment imaging, the way of treatment was obtained from patients' medical records. Data were analyzed using Pearsons' chi-square-test, descriptive statistics and Student's t-test. Results: 93.0% of the fractures were treated by open reduction and internal fixation (ORIF). MMO reduction was the most common post-treatment complication (55.6%). ORIF was associated with less pain after 3 months (p = 0.048) and lower VAS scores compared to conservative treatment (p = 0.039). Comminuted fractures were more frequently associated with post-treatment malocclusion (p = 0.048), FNP (p = 0.016) and MMO reduction (p = 0.001). Bilateral fractures were significantly accompanied by malocclusion (p = 0.029), MMO reduction (p = 0.038) and pain occurrence (p < 0.001). Conclusions: Patients report less pain after ORIF. Comminuted and bilateral fractures seem to be major risk factors for complications. Subjective perception of complications after extracapsular condylar fractures differs from objectively assessed data.

Parapharyngeal Space Tumors-What Lies in This Hidden Space?

The parapharyngeal or the lateral pharyngeal space is a potential anatomical space in the lateral neck extending from skull base to the hyoid bone. The fascial attachment between the styloid process and tensor veli palatini muscle divides this space into two compartments - pre styloid and post styloid. Primary tumors arising from this hidden space are quite rare and demand reasonable doubts and advanced surgical expertise in management. We describe our experience in managing these tumors and the varied surgical approaches.

Extremely Rare Case of Extra Skeletal Soft Tissue Chondroma of Masseteric Space: a Diagnostic Challengel.

Benign soft tissue chondroma is a rare type of extraskeletal chondrocytic tumour. It usually can be found in skeletal system in extremities. Head and neck region is one of the most uncommon sites for extraskeletal chondroma .Most common site is tongue and there has been paucity of cases arising from the other subsites .We present a case of 56 years gentleman who came to our OPD with a right masticator space swelling. It was nonmalignant on FNAC. He underwent wide local excision through a transparotid approach. Final biopsy & IHC report showed presence of benign chondrocytic neoplasm- soft tissue chondroma (extraskeletal). No further therapy was used and he has been in follow up since then. To our knowledge ,this is the third reported case of masseteric space chondroma. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-023-03705-5.

Treatment of extracapsular fractures of the mandibular condylar process: A retrospective evaluation of 377 cases.

BACKGROUND/AIM: Mandibular condylar fractures represent 25%-35% of all mandibular fractures. Despite profound research, there is still a controverse debate about treating these fractures conservatively or by open reduction and internal fixation (ORIF). The aim of this study is to analyse the outcome after open and closed treatment of extracapsular mandibular condyle fractures regarding general characteristics, post-treatment malocclusion, facial nerve palsy (FNP), maximum mouth opening (MMO) and parotid complications. METHODS: A retrospective cohort of 377 fractures (350 open, 27 closed treatment) was reviewed by reference to clinical and radiological pre- and postoperative documentation. Follow-up period was 12 months. Pearsons' chi-square-test, correlations, Kruskal-Wallis test and t-test were carried out for statistical analysis. RESULTS: The dominant type of fracture was type II in Spiessl and Schroll classification (50.1%). In the open treated fractures, the most common approach was retromandibular transparotid (91.7%). Post-treatment malocclusion occurred in 18.0% and was significantly increased in bilateral fractures (p = .039), in luxation fractures (p = .016) and in patients with full dentition (p = .004). After open reduction and internal fixation (ORIF), temporary FNP was documented in 7.1% whereas a permanent paresis occurred in 1.7%. FNP was significantly associated with high fractures (p = .001), comminution (p = .028) and increased duration of surgery (p = .040). Parotid complications were significantly associated with revision surgery (p = .009). Post-treatment reduction of MMO mainly occurred in female patients (p < .001) as well as in patients with bilateral fractures (p < .001), high fractures (p = .030) and concomitant mandibular (p = .001) and midfacial fractures (p = .009). CONCLUSION: Malocclusion seems to be the most frequent long-term complication after open reduction and osteosynthesis of extracapsular mandibular condyle fractures. We suggest ORIF by a transparotid approach to be an appropriate treatment with a low complication rate regarding especially FNP for extracapsular fractures of the mandibular condyle.

Resection of Primary and Recurrent Parapharyngeal Space Pleomorphic Adenomas via a Combined Transcervical-Transparotid Approach: A Case Series.

Primary parapharyngeal space tumors are rare, and due to the complex anatomy of the parapharyngeal space, their diagnosis and treatment are challenging. Pleomorphic adenoma is the most common histologic type followed by paragangliomas and neurogenic tumors. They can present as a neck lump or an intraoral submucosal mass with the displacement of the ipsilateral tonsil or might be asymptomatic and discovered incidentally on imaging obtained for other reasons. Magnetic resonance imaging (MRI) with gadolinium is the imaging of choice. Surgery remains the treatment of choice and many approaches have been described. In this study, we present three patients with PPS pleomorphic adenoma (two primary and one recurrent), which were resected successfully with a transcervical-transparotid approach without mandibulotomy. Division of the following anatomical structures: the posterior belly of the digastric muscle, stylomandibular ligament, stylohyoid muscle and ligament, and styloglossus muscle is a very important tip for the surgeons because enables displacement of the mandible providing excellent exposure for complete tumor excision. The only postoperative complication was temporary facial nerve palsy in two patients who fully recovered within two months. The aim of this mini case series is to present our experience, together with some tips and benefits of the transcervical-transparotid approach for the resection of pleomorphic adenomas of the PPS.

Different Approaches to the Overlapping Infratemporal Fossa and Parapharyngeal Spaces: a Case Series and Review of Literature.

Parapharyngeal space and infratemporal fossa are 2 overlapping spaces in head and neck which have complex anatomy with vital neurovascular structures passing through them. Tumors of this region are extremely rare but majority of them (80%) are benign. Benign tumors of this region can lead to swellings in facial region, neck and oropharynx. Dysphagia may be a complaint of the patient. Many of these tumors have malignant potential. Removal of these tumors requires a good understanding of the anatomy of this space so that correct surgical approach can be selected. The surgeon needs to be adept in using the most suitable surgical approach for excision of these tumors. There are various approaches which can be used to access these deeply seated tumors but the issue of prime importance is selecting the appropriate approach for the various tumors here based on their size and their exact location in this complex anatomical space. Inappropriate approach can lead to inadequate tumor excision and can lead to injuries to the neurovascular structures in this region which can cause significant disability. The case series reported here describes the various approaches to this region and highlights the importance of correct selection of the surgical approach.

Pre-auricular Transparotid Approach for the Management of Mandibular Condylar Fracture: An Experience of 82 Cases.

Purpose: This paper retrospectively analyses the functional outcomes and complications associated with pre-auricular transparotid approach for the management of mandibular condylar fractures. Material and Methodology: The retrospective data of 82 condylar fractures were analysing in 73 patients who underwent open reduction and internal fixation with pre-auricular transparotid approach. Evaluation of post-operative complications and the post-operative occlusion status, maximal inter-incise opening, adequacy of reduction and stability of fixation were assessed clinically and radiographically. Results: The exposure of fracture segment was adequate in all the cases, and fixation was easy with 2 mm delta miniplate. Transient facial nerve palsy occurred in 2 patients (2.43%). 1 patient developed sialocele which was managed conservatively. There were slight occlusal discrepancies in 10 patients at the end of 1-week follow-up which was corrected with guiding elastics at the end of 1-month follow-up. The reduction was adequate, and fixation was stable. The functional outcomes were satisfactory in term of mouth-opening and range of motion. Conclusion: The pre-auricular transparotid approach provides direct access to the fracture site resulting in less retraction of the tissue containing facial nerve and also less amount of periosteal stripping is required, thus it maintains good vascularity to the fracture segments. It provides direct visualization of the fracture without much retraction of the tissue containing facial nerve branches. It allows better fixation of the fracture with very less complication which results in good functional outcomes.

Management of parapharyngeal space tumors with transparotid-transcervical approach: analysis of prognostic factors related with disease-control and functional outcomes.

PURPOSE: Different therapeutic strategies have been developed to improve surgical and functional outcome of parapharyngeal space (PPS) neoplasms. The transparotid-transcervical approach (TTa) is a valid surgical option to manage most PPS tumors. Its short- and long-term disease control and cranial nerve (c.n.) function outcomes have not been discussed extensively. METHODS: All patients who underwent TTa over a 10-year period at a tertiary academic center were retrospectively reviewed. Data about preoperative imaging, clinical presentation, tumor's size, location and histology, and postoperative oncological and functional results were registered and analyzed. RESULTS: Sixty patients matched the inclusion criteria. Most of the lesions were benign (71.7%), involved the prestyloid PPS (63.3%) and measured more than 30 mm (75%). Fifty-two (86.7%) lesions were resected en-bloc. Clear margins were achieved in 91.7% of the cases, with positive margins solely associated with malignancy (p = 0.008). Post-operative c.n. function was satisfactory, with X c.n. function significantly associated with the retrostyloid location (p = .00) and neurogenic tumors (p = 0.02). Local disease-control was achieved in 96% of the cases after a median follow-up of 46 (± 19.7-82.0 IQR) months. CONCLUSIONS: The TTa was safe and effective, achieving a satisfactory local control rate. Nevertheless, malignancies maintain a higher rate of positive margin due to their infiltrative nature and the complex anatomy of the PPS. In such cases, multiportal approaches might be more effective. However, post-operative c.n. function remained satisfactory, irrespective of lesions' size and histopathologic behavior. A higher X c.n. deficit rate was observed in retrostyloid and neurogenic lesions.

Comparative Evaluation of Clinical and Radiological Outcomes of Retromandibular Transparotid and Transoral Endoscopic-Assisted Approach for Surgical Management of Mandibular Subcondylar Fractures.

STUDY DESIGN: A prospective randomized comparative study was conducted to evaluate the clinical and radiological outcomes of the retromandibular transparotid (RMT) approach with endoscopic-assisted transoral (ENDO) approach used for open reduction and internal fixation (ORIF) of adult mandibular subcondylar fractures. OBJECTIVES: To evaluate and compare the primary functional outcome using the Helkimo's dysfunction index, the surgical ease, the incidence of facial nerve weakness, the cosmetic outcomes and the number of complications following ORIF of mandibular subcodylar fractures using the RMT and ENDO approaches. METHODS: In this prospective study, 20 patients with unilateral/bilateral subcondylay fractures requiring ORIF were recruited between 2017 and 2018. Patients were randomly divided into RMT and ENDO group, 10 patients in each. Clinical and radiological assessment was done preoperatively and in postoperative period it was done at different intervals over the period of 6 months. The intraoperative parameter time taken during surgery was correlated for association with the time elasped since day of trauma and with the fracture severity. Similarly, the presence of multiple fractures of the mandible and postoperative occlusion were evaluated for the association. RESULTS: Comparable functional results were noted in both groups without any statistical significance. ORIF in ENDO group proved to be more time-consuming. For the RMT group, visible scars were rated best or close to best at the end of 6 months but a greater number of facial nerve injuries were reported in the RMT group. CONCLUSIONS: Superiority of one approach over others cannot be established since the outcomes were not statistically different. However, the ENDO approach appears to be safer. Therefore, there is a need for the development of innovative armamentarium which would improve the dexterity and ease of the surgeon and hence the total time taken for this minimally invasive approach for the management of subcondylar fracture.

Retromandibular transparotid approach for subcondylar mandibular fracture: A retrospective study.

INTRODUCTION: The retromandibular transparotid approach provides the shortest and the most direct access to mandibular sub-condylar fractures. However, this approach is less preferred due to the fear of facial nerve injury. The aim of this study was to evaluate the safety and morbidity of the retromandibular transparotid approach for open reduction and internal fixation of sub-condylar mandibular fractures. METHODS: A retrospective cohort study of 29 patients with 35 sub-condylar mandibular fractures who underwent open reduction and internal fixation through the retromandibular transparotid approach was conducted. The primary study variable was facial nerve palsy, whereas the secondary variables were infection, sialocele, salivary fistula, stability of the fractured segments, post-operative malocclusion, Frey's syndrome, and unesthetic scar. All patients were followed up for 6 months. Predictor variables included age, gender, side, location, displacement, etiology, concomitant maxillofacial fractures, and healing status. Fisher's exact test was calculated to find the association between primary variables and predictor variables. RESULT: Out of 35 sub-condylar fractures (29 patients; 23 male, 6 female), four (11.42%) developed transient facial nerve palsy. Fractures at the condylar neck level (P = .045) and with displacement (P = .026) were significantly associated with the development of facial nerve palsy. Four patients (13.8%) developed slight malocclusion, two had surgical site infections, two developed sialoceles, and one had a salivary fistula. CONCLUSION: The retromandibular transparotid approach is safe and effective with rare major complications in the management of sub-condylar fractures of the mandible. Condylar neck fractures and displaced fractured segments are associated with an increased risk of development of facial nerve palsy.

Ancient Schwannoma of the Infratemporal Fossa: A Case Report.

INTRODUCTION: Ancient schwannoma of infratemporal fossa arising from the trigeminal nerve is very rare in clinical practice. CASE REPORT: A 65-year old male presented to the outpatient department with a progressive swelling over the left parotid for 5 years and pain during chewing for 6 months which was diagnosed as benign spindle cell tumour on cytology. The tumor was excised with a combined transparotid and transmandibular cervical approach and the final pathology was confirmed to an Ancient Schwannoma. CONCLUSION: A giant infratemporal fossa Schwannoma extending to the parapharyngeal space masquerading as a parotid swelling is very unusual. Transparotid transmandibular excision of the infratemporal fossa tumor is an effective approach ensuring complete removal of the tumor with minimal postoperative complications and acceptable cosmoses.

The Retromandibular Transparotid Approach for Reduction and Internal Fixation of Mandibular Condylar Fractures.

INTRODUCTION: The retromandibular transparotid approach is most useful for condylar and subcondylar fractures and provides the best access to the joint and ascending ramus. The study aims at evaluating the ease of access and outcomes encountered on using the retromandibular transparotid approach to access the fracture site for the open reduction and internal fixation (ORIF) of condylar and sub-condylar fractures. MATERIALS AND METHODS: An observational clinical study was carried out among 10 patients with unilateral and bilateral condylar fracture requiring ORIF. Maximal interincisal mouth opening, facial swelling, occlusal discrepancy, facial nerve injury, scar formation, and acceptability and complications including wound dehiscence, infection, and sialocele/salivary fistula were assessed and measured preoperatively and postoperatively. RESULTS: There was a notable improvement in mouth opening and facial nerve weakness. Postoperative intermaxillary fixation was done with selective patients who had a discrepancy in their occlusion. Preoperatively, swelling was present in four patients (40%) out of 10 patients studied. There was no incidence of sialocele/salivary fistula in any of the cases studied. CONCLUSION: Retromandibular transparotid incision is technique sensitive and thorough knowledge about the retromandibular area is must for good results and minimal morbidity. The cosmetic results are good in this approach, as well as the facial nerve injury were less in this without any permanent damages.

Open Treatment of Mandibular Condyle by Direct Transparotid Approach: Our Experience.

The fractures of the mandibular condyle are commonly encountered in maxillofacial surgical practice. The controversies to open or not to open are still ongoing. We have used both techniques, to successfully manage our patients. Open treatment of condyle fracture with or without dislocation is technically challenging. We used a "Direct Transparotid" approach in treating 13 condyle fractures over a period of 4 years. The patients were evaluated for facial nerve injury, salivary fistula, scar, function, and occlusion over a period of 12 months. There were no major complications with acceptable scar, both intraoperatively and postoperatively. The script aims at presenting our experience of direct transparotid approach surgical technique.

Biportal transparotid dissection in the retromandibular approach for condylar fracture osteosynthesis: Efficacy of a novel technique.

OBJECTIVE: Facial nerve injury is a primary complication of open surgical management of condylar fractures. A new modification of the retromandibular transparotid approach, the "biportal transparotid dissection" (BTD), was developed to reduce these injuries in accidental nerve exposure. DESIGN: Prospective cohort study. SETTING: Tertiary referral center. METHODS: Patients managed by retromandibular transparotid approach for condylar fractures at Department of Otolaryngology - Head and Neck Surgery, Mansoura University were included between November 2015 and August 2019 with exclusion of cases managed endoscopically or by a closed approach. Three groups were identified: Group A included patients undergoing the BTD technique, which entails transparotid dissection above and below exposed nerve branches and minimal nerve retraction; Group B included patients undergoing traditional dissection and nerve retraction away from the surgical field; and Group C included patients with unidentified facial nerve branches. The function of facial nerve branches was documented postoperatively. RESULTS: Fifty-seven fractures were included in the study. Facial nerve branches' injury occurred in 13 cases (22.8%): two (of ten) in Group A (20%), seven (of ten) in Group B (70%) and four (of 37) in Group C (10.81%). Compared to patients with non-exposed branches, Groups A and B were found to have 2.06 (p = 0.447) and 19.25 (p = 0.001) greater odds of nerve injury, respectively. The results showed significant faster nerve recovery in the BTD group compared to traditional dissection (mean 5 versus 9 weeks) (p = 0.015). CONCLUSION AND RELEVANCE: Although avoiding facial nerve exposure minimizes injury the most, BTD approach reduces exposed nerve injury compared to the traditional method.

Variations in the retromandibular approach to the condyle-transparotid versus anteroparotid transmasseteric - a prospective clinical comparative study.

BACKGROUND: The management of mandibular condylar fracture remains controversial many surgeons still favour the open reduction and internal fixation (ORIF) which provides good result and immediate functioning as compared to closed reduction. With proven consensus for ORIF, dilemma remains in choosing the surgical approach to condyle due to proximity of complex and important anatomic structure. Various extra-oral surgical approaches are available for ORIF including preauricular, submandibular, retromandibular, transmasseteric anteroparotid etc. Variations in retromandibular approach such as transparotid, retro-parotid and anteroparotid are reported in literature. In our study we compared the retromandibular transparotid and retromandibular anteroparotid transmasseteric variations. METHODOLOGY: Thirty condylar fracture in 26 patients, 15 in each group (group A - Retromandibular transparotid approach & group B - Retromandibular anteroparotid approach) were treated under general anaesthesia with naos-tracheal intubation and by the same surgeon having 20 years of experience in maxillofacial surgeries. We evaluated time taken for the procedure, amount of bone exposure, intra-operative haemorrhage. Postoperative presence of infection, sinus and fistula formation at the incision site, parotid fistula formation, facial nerve functioning using House-Brackman scale in immediate postoperative period, 3rd month postoperatively and 6 month postoperatively. RESULT: The mean average time taken for group A was 78.2minutes and mean average time taken for group B was 64.8minutes. None of the patient had haemorrhage intra-operatively in both the groups. Exposure was sufficient in both the groups with same length of the incision. None of the patient suffered from postoperative infection in both the groups. Parotid fistula formation was present in 2 patients in group A while none of the patient had parotid fistula in group B. Three patients out of 15 had the transient facial nerve weakness in group A which got resolved in 6 month while none of the patient had facial nerve weakness in group B. All patients had adequate mouth opening with no occlusal discrepancies. CONCLUSION: Retromandibular anteroparotid approach as described in this study has proven to be an extremely useful approach provides good access, and associated with minimal complications and morbidity compare to retromandibular transparotid approach. It is hence safe to say that this approach is relatively useful for an inexperienced and novice surgeon as well.

Retromandibular transparotid approach compared with transmasseteric anterior parotid approach for the management of fractures of the mandibular condylar process: a prospective randomised study.

Fractures of the mandibular condyle lead to displacement of the condyle and loss of the height of the ramus. A retromandibular approach is the most commonly used for open reduction and internal fixation (ORIF) of such fractures. We aimed to compare the complications associated with a retromandibular transparotid approach with a retromandibular transmasseteric anterior parotid (TMAP) approach for their management. Thirty patients were randomly selected into two groups (15 in each): Group A comprised the retromandibular transparotid approach and Group B the retromandibular TMAP. The variables evaluated were: operating time, facial nerve injury, occurrence of Frey syndrome, and sialocoele at one week, four weeks, three months, and six months. The mean (SD) age in group A and B was 33.93 (17.97) years and 33.53 (16.15) years, respectively, and there were 28 men and two women. Mean (SD) exposure time in the transparotid approach was 26.93 (5.19) minutes and 25.4 (8.35) minutes in the TMAP approach. The incidence of facial nerve injury was 2/15 patients in the transparotid group and 3/15 in the TMAP group, all of which resolved within six months. The incidence of sialocoele was 2/15 in the transparotid group. The results did not show any significant difference in complications between the two approaches, but the retromandibular transparotid approach provided straight-line access in fractures of the condylar neck, with fewer incidences of nerve injury. The anterior parotid approach, on the other hand, provided easier access for fractures that were medially dislocated or of the condylar base but had an increased incidence of facial nerve injuries.

True Parapharyngeal Space Tumors: Case Series from a Teaching Oncology Center.

The Parapharyngeal Space (PPS) tumors are rare tumors accounting for 0.5% of the tumors in head and neck region. A retrospective study conducted at Department of Surgical oncology, Vydehi institute of Medical Sciences & Research center, Bengaluru, between 2010 and 2015 identified nine cases treated for PPS tumors. Patients are diagnosed on the basis of clinical examination fine needle aspiration cytology and imaging and considered for excision by one of the varied surgical approaches {transoral(1), transcervical(4), transparotid(0), transcervical-transparotid(1), transmandibular(3) or intratemporal(0) approach}. The choice of approach is defined by the size of the tumor, suspicion of malignancy and the position of the tumor with regard to the superior extent and proximity to the skull base as well as its relation with neurovascular bundle.

Experience with the transparotid approach via a mini-preauricular incision for surgical management of condylar neck fractures.

INTRODUCTION: The aim of this study was to describe our experiences of a mini-preauricular transparotid approach for direct reduction and plating of condylar neck fractures. MATERIALS AND METHODS: A retrospective study was conducted on 58 patients from 2009 to 2011 with 69 condylar neck fractures in Chang Gung Memorial Hospital. The fractures were treated surgically either with a 2-cm mini-preauricular and transparotid approach in 29 patients with 36 fractures, or via endoscope-assisted intraoral, or facelift or retromandibular approaches in a control group of 29 patients with 32 fractures. The postoperative hospital stay, occlusion status, mouth opening and facial nerve and parotid gland related complications were compared between the two groups. RESULTS: In both groups around 90% of patients had good restoration of preinjury occlusion. Postoperative mouth opening was 39.8 mm and 39.9 mm in the mini-preauricular approach and the other approaches group, respectively. Facial symmetry was achieved in all of the patients. There was no incidence of facial nerve palsy, infection or hemorrhage in the mini-preauricular group. One patient in the control group had a persistent weakness due to frontal nerve palsy. CONCLUSION: Based on the results, the mini-preauricular approach can be an alternative, safe and effective method in the management of condylar neck and high subcondylar fractures.