Incision Selection in Mandibular Angle ORIF: Postoperative Complications and Neurosensory Outcomes by Approach

Mandibular angle fractures carry disproportionate postoperative morbidity, yet optimal incision selection remains controversial despite its clinical importance.

The aim of the study was to evaluate whether incisional approach, particularly trocar-assisted transbuccal access, is independently associated with any postoperative complication, including postoperative paresthesia, after ORIF of mandibular angle fractures.

A retrospective cohort of consecutive patients undergoing ORIF for mandibular angle fractures was analyzed with respect to incision approach, including intraoral, transparotid, retroparotid/submandibular, and trocar-assisted transbuccal. The primary endpoint was any postoperative complication; secondary outcomes included infection, paresthesia/neuropraxia, return to the operating room (RTOR), and postoperative third molar extraction. Multivariable logistic regression adjusted for age, body mass index, smoking status, isolated angle fracture, comminuted and/or displaced fracture, and intraoperative third molar extraction.

Among 116 patients, median age and body mass index were 31.7 years (interquartile range, 23.4-46.3) and 24.4 kg/m 2 (interquartile range, 21.9-27.8), respectively. Incisional approaches were intraoral (n = 65), transparotid (n = 15), retroparotid/submandibular (n = 9), and trocar-assisted transbuccal (n = 27). Any complication occurred in 27/115 patients with postoperative follow-up (23.5%), with the highest unadjusted rate in the trocar-assisted transbuccal cohort (48.1%). In adjusted analysis (reference: intraoral), trocar use was associated with higher odds of any complication (OR, 6.22; P  = 0.002), with no significant differences for transparotid or retroparotid/submandibular approaches. With trocar-assisted transbuccal as the reference, intraoral (OR, 0.18; P  = 0.003) and transparotid (OR, 0.07; P  = 0.024) approaches were protective. Among patients with documented neurologic assessment (n = 32), trocar use (OR, 8.63; P  = 0.022) and intraoperative third molar extraction (OR, 6.61; P  = 0.038) were associated with higher odds of neuropraxia. No adjusted incision-specific associations were observed for infection, postoperative third molar extraction, or RTOR.

These findings support risk-aligned incision selection, suggest that trocar-assisted transbuccal access may warrant selective use in anatomically or mechanically constrained cases, and reinforce standardized documentation of postoperative nerve dysfunction to enable more reliable benchmarking and guide pragmatic decision-making across centers.