Surgeon(s): ***

‍Assistant Surgeon(s):  ***

‍Preoperative Diagnosis: ***

‍Postoperative Diagnosis: Same

‍Procedure(s): ***

‍Anesthesia: General

‍Implants: None

‍Specimen:***

‍Drains: None

‍Fluids: See anesthesia record

‍EBL: Minimal

‍Complications: None

‍Counts:  Correct x2

‍Indications: ​***

‍Findings: As expected

‍Procedure in Detail:

‍The patient was seen in the preoperative holding area with a H&P was updated, consents were verified, surgical site marked, and all questions and concerns related to the proposed procedure were discussed in detail.  The patient was transferred to the operating room by the anesthesia team.  The patient underwent general anesthesia with endotracheal intubation. Tegaderms were placed over the eyes. The patient was prepped and draped in the standard fashion for maxillofacial procedures.  A time-out was performed and the procedure began.

Teeth were brushed with Betadine and rinsed with saline irrigation. A K-wire was placed at the nasofrontal junction and the reference vertical height to maxillary incisor bracket was measured. Occlusal interferences were removed with a round diamond bur. Next, attention was turned to the patient's right mandibular vestibule. A #15 blade was used to make a BSSO type incision. The incision was carried out through mucosa to muscle and then carried horizontally down to bone. Then using a #9 periosteal elevator, dissection continued inferiorly and posteriorly to expose the entire inferior and posterior border of the mandible. Next, attention was turned to extract the fully bony impacted tooth #32. Using a 702 fissure bur, bone was removed and the tooth was sectioned and subsequently delivered with elevators and forceps. The entire extraction socket was copiously irrigated with sterile saline. Dissection then continued to proceed medially with a #9 elevator and a notched toe-in retracted was placed on the coronoid process. Next a baur retractors was placed at the inferior border. A prefabricated drill guide was adapted over the angle of the mandible.  This was then accessed with a trocar system, first making a nick incision with a #15 blade and then placing the trocar with a cheek retractor to aid in visualization. Proximally and distal screw holes were then pre-drilled.  Next, the horizontal cut of a mandibular inverted L osteotomy was made using a reciprocating saw.  Then, the vertical cut was made with an oscillating saw, leaving a small area of mandible intact. Once finished, the drill guide was removed and a pre-bent KLS reconstruction plate was placed at the angle of the mandible.  The proximal portion was fixated bicortical screws.  Following this the vertical osteotomy was completed with the oscillating saw.  The surgical site was then copiously irrigated and packed off with moist gauze.

Attention was then directed at the left side. A #15 blade was used to make a BSSO type incision. The incision was carried out through mucosa to muscle and then carried horizontally down to bone. Then using a #9 periosteal elevator, dissection continued inferiorly and posteriorly to expose the entire inferior and posterior border of the mandible. Next, attention was turned to extract the fully bony impacted tooth #17. Using a 702 fissure bur, bone was removed and the tooth was sectioned and subsequently delivered with elevators and forceps. The entire extraction socket was copiously irrigated with sterile saline. Dissection then continued to proceed medially with a #9 elevator and a notched toe-in retracted was placed on the coronoid process. Next a baur retractors was placed at the inferior border. A prefabricated drill guide was adapted over the angle of the mandible.  This was then accessed with a trocar system, first making a nick incision with a #15 blade and then placing the trocar with a cheek retractor to aid in visualization. Proximally and distal screw holes were then pre-drilled.  Next, the horizontal cut of a mandibular inverted L osteotomy was made using a reciprocating saw.  Then, the vertical cut was made with an oscillating saw, leaving a small area of mandible intact. Once finished, the drill guide was removed and a pre-bent KLS reconstruction plate was placed at the angle of the mandible.  The proximal portion was fixated using bicortical screws.  Following this the vertical osteotomy was completed with the oscillating saw.  The surgical site was then copiously irrigated and packed off with moist gauze.

Next using a prefabricated intermediate occlusal stent the patient was placed elastic rubber bands. The proximal and distal segments were noted to be free of interference and the mandibular condyles were noted to be easily seated in their most superior and posterior position, taking care not to seat them with too much pressure. The remaining screws were placed in the distal segments of both sides of the custom plates. The patient was then released from maxillomandibular fixation. It was noted that the patient was biting easily into the splint without any interferences or slides.

‍

‍

The patient's face was then cleaned and the posterior pharynx was suctioned. An OG tube was used to suction out the contents of the stomach. Tegaderms were removed from the eyes. Dressings were placed. The patient was then transferred back to the care of the anesthesia team for extubation and recovery.

‍

‍