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 had received preoperative IV unasyn antibiotics. Once a timeout was completed oral cavity was thoroughly suctioned with the Yankauer suction the moist vaginal packing was used it as a throat pack. Patient was given local anesthesia via local blocks and infiltration for oral maxillofacial procedures using 1% lidocaine with 1 to 100,000 epinephrine per anesthesia record as well as 5% Marcaine with 1 to 200000 epinephrine per anesthesia record. Synthes leave hybrid MMF Arch bars were fashioned in the maxilla and 8 mm screws x5 Were used to secure the hybrid arch bar. A segmental hybrid MMF arch bar was fashioned in the proximal aspect of the right posterior mandible ans was secured with 8mm screws. Three Synthes 8mm IMF screws were placed in the left mandible and right anterior mandible.
Attention was then directed to The right mandible where the draining right mandibular fistula was noted in the area of the superior border plate. The right submandibular abscess was then massaged and copious purulent material was drained this purulent material was collected and sent off for specimen. Attention was then directed towards non restorable teeth 29 and 30 which were elevated and delivered without complication; the sites were copiously curetted with curette sites were irrigated with copious saline impregnated with neomycin antibiotic; tissues were re-approximated and closed with 3-0 chromic gut suture in a figure-of-eight fashion.
We were able to manipulate the mandible to obtain good occlusion and to get adequate reduction of the mandible segments. We then placed the patient into intermaxillary fixation with 24-gauge wires. Once The patient was in maxillomandibular fixation the oral cavity was then prepped with a large Tegaderm. The patient was re-prepped and draped for extraoral procedure.
Attention was then directed to the Right body of mandible fracture. The patient was redraped. Attention was directed to a natural fold it within the skin approximately 2 finger breadths from the inferior border of the mandible. It was ensured that the patient was not placed under long-term neuromuscular blockade. The nerve stimulator was used at this point of the case. An incision was made approximately 3 cm wide through skin, subcutaneous tissue, with blunt dissection as well as electric cautery through the platysma muscle once the superficial layer of the deep cervical fascia was and countered blunt dissection as well as sharp dissection was used to bluntly dissect and identify the right facial artery. This was tied off using 3 0 silk ties. This was sharply cut with a 15 blade. Then soft tissue dissection was then taken deep to the facial artery encountering the pterygomasseteric sling. Once this was dissected through to periosteum electric cautery was then used to dissect through periosteum identifying the inferior border of the mandible. It was noted that dish soap appearing drainage was expressed at this time. Subperiosteal dissection was then carried superiorly identifying both mandibular plates. Both plates were noted to be loose with copious granulation tissue around the screws. Both the superior border as well as inferior border plate was removed. The nonunion was then identified and Debridement of the right mandibular nonunion was taken place debriding mucosa, bone, as well as muscle. Once this was debrided, the mandibular nonunion was Curetted as well as filed with a rasp down to bleeding bone. Several bur holes were placed in a rapid accelatory phenomenon type fashion in order to promote angiogenesis within the site. The site was irrigated with copious amounts of antibiotic impregnated irrigation. There appeared to be a very small gap between segments however the segment did appear to be multiple. A new Synthes inferior border plate was then adapted and secured with 4 10 mm bicortical 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 incision was closed with 3-0 vicryl for deep. A 3/8″ penrose drain was then placed within the subplatysmal plane. 4-0 vicryl was used to close the subcutaneous tissues. A 5-0 prolene was then used to close the skin in a running fashion. Hemostasis was achieved. The skin incision was then dressed with Telfa, benzoin tincture, as well as a Tegaderm.
Attention was then directed intraorally once again. Patient was released from intermaxillary fixation. The oral cavity was thoroughly irrigated with sterile saline impregnated with antibiotic. Suctioned with the Yankauer suction, moist vaginal packing was then removed and the oropharynx was also suction thoroughly. All surgical sites were once again reevaluated and found to be hemostatic. Patient was placed back into intermaxillary fixation with 24-gauge wires ×4 with good occlusion achieved.
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.
