The patient was greeted in the preoperative area. All the risks and benefits of the procedure were once again explained and the risks of malocclusion, nonunion, malunion, pain, bleeding, infection, swelling, permanent nerve dysfunction including lower chin and lip numbness were explained in detail all questions were answered. Consent had already been signed. Care was then handed back to the anesthesia team.
The patient was brought into the operating room by the anesthesia team and the patient was placed in a supine position where the patient remained for the rest of the case. Anesthesia was able to establish a nasotracheal intubation without any complications. Care was then handed back to the OMFS team.
Patient was draped in sterile manner. Timeout was performed in which the patient was correctly identified by name medical record number as well as a site of the procedure be performed. Patient has been on amoxicillin PO q8h and was kept on schedule for appropriate abx coverage. Once a timeout was completed, the oral cavity was thoroughly suctioned with the Yankauer suction and a moistened throat pack was palced. Patient was given 10cc 1% lidocaine with 1:100k epi via bilateral IAN block and local infiltrations near the sites of the fracture. 6 IMF screws were placed.
We were able to manipulate the mandible to obtain good occlusion and to get adequate reduction of the mandible segments. Attention was initially directed to the right parasymphysis fracture. Electrocautery was used to make an incision extending from tooth #24 to #30. Periosteal elevator was used to expose the right parasymphysis fracture with adequate exposure to place a 6-hole fracture plate. Next attention was then directed to the left mandibular angle. Electrocautery was again used to make an incision extending from the level of the ascending ramus through the mucosa and submucosa to the periosteum just distal to tooth #19. A sub-periosteal dissection was then carried out superiorly,anteriorly, and to the inferior border of the mandible. The fracture was visualized. The site of the fracture was grossly debrided using curettes and irrigated copiously. Good approximation of the fracture segments was achieved. We then placed the patient into intermaxillary fixation with 22-gauge interdental wires. A Stryker fracture plate was adapted to the inferior border over the right parasymphysis fracture. This plate was secured with six 12mm bicortical screws. Next, s prebent Champy plate was adapted to the left mandibular angle. This plate was fixated with four 5mm screws. A second plate was adapted at the inferior fracture site of the left mandibular angle fracture. A 0.5cm incision was made a transcutaneous trochar was used to fixate this plate with three 10mm screws. Good reduction of the fracture was obtained. Patient’s occlusion was good with bilateral balanced contacts. The surgical site was thoroughly irrigated with sterile saline. The IMF was released and the occlusion was stable and reproducible. The 6 IMF sscrews were removed. The surgical sites were irrigated copiously with normal saline. The mentalis was resuspended with 3-0 Vircyl sutures. The mucosa was closed with 3-0 chromic gut suture in a running fashion. Hemostasis was achieved.
The oral cavity was thoroughly irrigated with normal saline. The oral cavity was suctioned with the Yankauer suction, and the throat pack was removed. An oropharyngeal tube was utilized to suction any remnant fluids prior to extubation. 9cc of 0.5% marcaine with 1:100k epi was given via local infiltrations around the surgical sites. All surgical sites were once again reevaluated and found to be hemostatic.
Care was then handed back to anesthesia team where the patient was extubated in the operating room without any complications and then transferred to the postanesthesia care unit.
