FINDINGS
This is a ***-year-old *** with a significant dental facial deformity who will undergo maxillary mandibular osteotomies. The case was discussed at length with patient. Risks, benefits, and alternative therapies reviewed. The clinical indications discussed, understood, and accepted. Risks of bleeding, infection, hardware failure, injury to the inferior alveolar nerve, and reoperation were discussed, understood, and accepted. The patient is being taken to the operating room in an elective manner.
PROCEDURE
The patient was taken to the OR and placed on the OR table in the supine position. The patient was induced under general anesthesia and maintained via nasotracheal intubation. The patient was prepped and draped in the standard fashion for an orthognathic reconstructive procedure.
The oropharynx was thoroughly suctioned. A posterior throat pack was placed. Approximately 10 mL of 1% Xylocaine with epinephrine was infiltrated to the maxillary mucobuccal fold.
With the use of a needle tip Bovie, a standard degloving incision was initiated 1 cm superior to the mucogingival line above the left bicuspid and carried across midline to the contralateral side. Sharp tissue dissection proceeded in a subperiosteal plane degloving the facial aspect of the maxillary complex. A prefabricated surgical guide was placed onto the facial aspect of the maxilla into an appropriate anatomical position and fixated with monocortical screws. The cutting guide determined the predictive hole placement for the custom plate, which was previously manufactured, and the level and dimension of the osteotomy. Once fixation holes were predrilled and the osteotomy outlined, the cutting guide was removed. Using a reciprocating saw, the osteotomy was completed through the outlined template without complication in a standard manner separating bone from the zygomatic buttress to the piriform in a bilateral manner.
Posterolateral maxilla and lateral nasal walls were separated with the use of a single-guarded osteotome. Pterygomaxillary disjunction was completed with the use of a curved osteotome. The nasal septal complex was separated from the palatal shelf with the use of a double-guarded olive chisel.
Firm digital pressure was placed on the anterior maxilla, and a down fracture was achieved. Nasal mucosa was to the posterior palatal rim, and the maxilla was engaged with the use of Rowe disimpaction forceps. In a down fractured position, the descending palatine artery on the right side was identified and ligated to allow for ostectomy of the posterior medial aspect of the maxilla. On the left side, the left descending palatine vessel was not impinging on skeletal movement. The maxillary mandibular complex was placed into intermaxillary fixation with a prefabricated interocclusal splint. The complex was rotated along the arc of closure of the mandibular condyles. Appropriate vertical dimension was gained with the use of the custom plates engaging the predictive holes. The maxilla was fixated in the standard manner with and noted to be stable.
Approximately 10 mL of 1% Xylocaine with epinephrine was infiltrated into the proposed incision sites of the posterior mandible. With the use of a needle tip Bovie, a standard degloving incision was made along the lateral aspect of the ascending ramus, extended over the substance of external oblique ridge and into the mucobuccal fold adjacent through the first molar. Soft tissue dissection proceed in the subperiosteal plane degloving the mid corpus and posterior body of the mandible, extended along the external oblique ridge and onto the ascending ramus. Further dissection onto the medial cortex with isolation of the bony lingula and retraction medially of the neurovascular bundle was completed. Good exposure of the anatomical landmarks were gained, and with the use of a reciprocating saw, a medical corticotomy was initiated posterior and superior to the bony lingula, extended through the substance of the ramus in a vertical Fashion, through the external oblique ridge and onto the buccal cortices adjacent to the 2nd molar. Vertical corticotomy to the inferior border was completed, and the inferior border was scored with the use of the inferior border saw. The corticotomy was revised with the use of the Sonopet harmonic saw to insure appropriate cortical separation. Once separation was noted throughout, initial separation of the osteotomy was completed with the use of multiple osteotomes and chisels. Final separation was gained with the use of 2 Smith spreaders. Upon separation, the neurovascular bundle was noted to be within the distal segment.
Attention was then directed to the contralateral side in which a similar incision and dissection was completed. All anatomical landmarks were identified, and the osteotomy was proceeded in the similar fashion without complications. Upon good separation, the dentate portion of the mandible was manipulated and placed into an interocclusal splint, and into intermaxillary fixation. The proximal segments were manipulated in the posterior-superior fashion to allow for appropriate condyle fossa relationship, and reinforced mini plates placed in a standard manner onto the buccal cortex, bridging the osteotomy for stability. Good stability was gained. Intermaxillary fixation was removed. The patient demonstrated the appropriate arc of closure and dental occlusion.
The oropharynx was thoroughly suctioned and posterior throat pack was removed. All surgical sites were irrigated, and the wounds were closed with the use of 3-0 Vicryl and 3-0 chromic sutures. The patient was extubated in the operating room and taken to the recovery room in stable condition.
