Int. J. Oral Surg. 1982: 11: 197-200

(Key words: osteotomy, sagittal.' sur/?ery. corrective; syndrome, Frrp,' nerve, aur;cl//o-tempuraf)

Frey's syndromeA complication after sagittal splitting of the mandibular ramus

D. B. TUINZING AND W. A. M. VAN DER KWAST

Department oj Oral Surgery, Free University, Amsterdam, The Nether/ands

ABSTRACT - The occurrence of the auriculo-temporal syndrome (Frey'ssyndrome) after the correction of mandibular prognathism by a sagittal splittechnique is reported.

(Receil'edjor publication 18 August, accepted 10 November 1981)

The auriculo-temporal syndrome is charac­

terized by facial sweating and flushing confinedto the sensory distribution of the auriculo­temporal nerve ll • FREy4 attributed these sym­ptoms to scar formation around the auriculo­

temporal nerve after damage caused by par­otidectomies', condylar fractures I0,12, and after

a sllbcondylar osteotomy2. A case in which

these symptoms appeared after an uncontrolled

sagittal split of the mandibular ramus will bepresented.

Case reportA 24 year-old-male (Fig. I) was referred by thephysician becau,~ of chewing problems. Orthodontictreatment h.,<.1 L,,<:n place over a period of 8 years(using a chin-cap) to correct mandibular prognath­ism. The sagittal overbite was 6 mm with an overjet ofI mm. Study models showed the feasability ofcreatinga stable occlusion with good interdigitation after amandibular setback of 8 mm.

Under general anaesthesia, a sagittal split os­teotomy was performed in both rami. On the rightside, however, an unwanted fracture, resulting in ahorizontal ramus osteotomy, occurred. On this side,sufficient posterior movement of the mandible was

impossible. Temporary intermaxillary fixation andelastic bands were applied, in an attempt to move themandible into the correct (3 mm more posterior)position.

Postoperatively the patient complained of severepain in the right ear, which decreased after removal ofthe elastic bands. Radiologic examination showedcranial displacement of the condylar fragment (Fig.2). Under local anaesthesia the condylar fragment waswired to the ramus and although the occlusion wasnot as planned preoperatively, a reasonable occlusionwas reached after selective grinding of the dentition(Fig. 3).

After It years the patient developed the symptomsof the Frey syndrome: gustatory sweating andflushing in front of the right ear. These phenomenastarted shortly after eating hot food and after food,which needed mastication.

5 years postoperatively, these complaints havediminished considerably.

DiscussionAs a superficial review of the neuroanatomy

shows, the auriculo-temporal nerve carries

sympathetic fibers, which innervate the sweatglands and parasympathetic fibers, innervating

the parotid gland. Sweat glands and parotid

0300-9785/82/030197-04$02.50/0 © 1982 Munksgaard, Copenhagen

198 TUINZING AND VAN DER KWAST

Fig. I. A 24-year-old patient, referred because of chewing problems.

gland, although under control of differentsystems (sympathetic and parasympathetic)have the cholinergic transmission in common.

A theory (HAXTON') which attempts toexplain gustatory sweating occurring im­mediately after trauma, suggests that thesensitivity of the sweat glands to acetylcholine isincreased after damage to the sympathetic fibersof the auriculo-temporal nerve. According tothis assumption, stimulation of the salivaryglands (cholinergic transmission) activates thehypersensitive sweat glands as well. Another,generally more accepted theory explains theonset ofgustatory sweating some period of timeafter trauma, thus: during injury to theauriculo-temporal nerve both sympathetic andparasympathetic fibers are damaged; a mis­directed regeneration of parasympathetic fibersto denervated sweat glands results in simul­taneous activation of parotid- and sweat glands(Fig. 4). Follow-up studies concerning thesagittal split technique pay much attention tothe sensibility of the lower alveolar nerve.DENDY' reports facial nerve paralysis followinga sagittal split osteotomy, while occasionallydamage to the buccal nerve is mentioned.

In the case presented, on 3 occasions damageto the auriculo-temporal nerve may haveoccurred: primarily during the attempt to bringthe mandible into the planned position withelastic band-traction; contusion ofthe auriculo­temporal nerve between the posterior border ofthe mandible and the mastoid bone may have

Fig. 2. Condylar displacement occurring after ahorizontal fracture of the mandibular ramus.

FREY'S SYNDROME 199

Fig. 3. Postoperatively, the patient shows a good profile and a reasonable occlusion.

taken place; secondly during the splitting bydriving the chisel too far posteriorly and thirdlyduring the wiring of the condylar fragment tothe mandibular ramus.

According to JONSSON et aP, unwantedfractures of the mandibular ramus by thesagittal split technique occur in 70% of casesand may be predicted by the radiographicappearance of the region above and in front ofthe mandibular angle9

•

Fracture in the horizontal cut can be avoidedby using the modified sagittal split technique"(Fig. 5).

Fig. 4. Injury to the auricula-temporal nerve ([orinstance after a parotidectomy) may result ingustatory sweating creused hy misdirected regener­ation o[ parasympathetic fibers.

Fig. 5. The modified, sagittal split technique(Hunsuck) may avoid a horizontal fracture of themandibular ramus.

200 TUINZING AND VAN DER KWAST

TreatmentTreatment of the auriculo-temporal syndromemay consist of intracranial dissection of the

glosso-pharyngeal nerve. This method is effect­ive but extremely drastic for the degree ofdisability.

Topical treatment with 3% scopolamine issuggested; however, the instance of cutaneous

sensitization seems significant. The insertion offascia lata seems to give satisfactory results asreported recently by BADDOUR et al. I.

Fortunately, in our case the degree of

gustatory sweating has considerably decreased,5 years postoperatively.

Only very salty foot (herring) provokes the

symptoms of the auricula-temporal syndrome.

No treatment is indicated.

References1. BADDOUR, H. M., RIPLEY, J. F., CARTEZ, E. A.,

McANEAR, J. T., STEED, D. 1. & TILSON, H. B.:Treatment of Frey's syndrome by an inter­positional fascia graft. J. Oral Surg. 1980: 38:778-781.

2. CIflSNA, N., MENDELSON, C. G. & DARNLEY, J.D.: Auriculo temporal syndrome. Arch.DermatoJ. 1964: 90: 457-459.

3. DENDY, R. A.: Facial nerve paralysis following

sagittal split mandibular osteotomy. Br. J. OralSurg. 1973: 11: 101-105.

4. FREY, 1.: Le syndrome du nerf-auriculo tem­poral. Rev. Neurol. 1923: 2: 97-104.

5. HAXTON, H. A.: Gustatory sweating. Brain 1948:71: 16-25.

6. HUNSUCK, E. E.: A modified intraoral sagittalsplit technique for correction of mandibularprognathism. J. Oral Surg. 1968: 26: 250-253-

7. JONSSON, E., SVARTZ, K. & WELANDER, U.:Sagittal split technique. Int. J. Oral SlIrg. 1979: 8:75-94.

8. LAAGE-HBLLMANN, J. E.: Treatment of gustatorysweating and flushing. Acta Otolaryngol. 1958:49: 132-143.

9. MERCIER, P.: The inner osseus architecture andthe sagittal splitting of the ascending ramus of themandible. J. Max. Fac. Surg. 1973: I: 171-176.

10. SCHMIDSEDER, R. & SCHEUNEMANN, H.: Nerveinjury in fractures of the condylar neck. J. Max.Fae. Surg. 1977: 5: 186-190.

II. SHAFER, W. G., HINE, M. K. & LEVY, B. M.: Atextbook of oral pathology. W. B. SaundersCompany, Philadelphia 1974, pp. 799.

)2. STORRS, T. J.: A variation of the auriculo­temporal syndrome. Br. J. Oral Surg. 1974: 11:236-241.

Address:

D. B. TuinzingAcademise1l Zieken1luis der Vrije Universiteit.Afd. Mondziekten en Kaakchirurgie1007 MB AmsterdamDe BoeleJaan ]J17The Netherlands