Mandibular Vertical Ramus Osteotomies Operative Sample Report
DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSIS: Mandibular hyperplasia, skeletal class III jaw deformity with flap retruded chin contour.
POSTOPERATIVE DIAGNOSIS: Mandibular hyperplasia, skeletal class III jaw deformity with flap retruded chin contour.
OPERATION PERFORMED: Bilateral mandibular vertical ramus osteotomies with skeletal/dental intermaxillary fixation and sliding horizontal mandibular osteotomy.
SURGEON: John Doe, MD
ANESTHESIA: General.
ANESTHESIOLOGIST: Jane Doe, MD
INDICATIONS FOR OPERATION: The patient is a (XX)-year-old male who for many years has noted an overdevelopment to his lower jaw resulting in a large underbite making eating difficult and causing jaw joint dysfunction. The patient has undergone presurgical orthodontic preparation and is now to undergo mandibular osteotomies for correction of his jaw deformity.
DESCRIPTION OF PROCEDURE: The patient was taken to the operating area in sedated condition and placed in a supine position on the operating table. After the successful induction of anesthesia and placement of nasal endotracheal tube, the patient was prepared and draped in the usual manner for intraoral surgical procedure. Attention was directed intraorally. The oropharynx was suctioned freed of all secretions and debris and moist pack was removed from about the endotracheal tube. Then, 2% Xylocaine with 1:100,000 epinephrine was infiltrated into the medial and lateral ramus, anterior into the symphysis. Bilateral and inferior orbital alveolar nerve blocks were accomplished with 2% Xylocaine, 1:100,000 epinephrine and 0.5% Marcaine with 1:200,000 epinephrine.
Attention was then directed to the maxillary and mandibular dentition where several areas of enamel on the teeth needed to be recontoured with a diamond bur. Ivy-Loop appliances were applied to the molar dentition and the right and left posterior maxillae, on both the right and left side for intermaxillary fixation.
At this time, attention was directed to the right ramus area where we used #15 Bard-Parker blade. Incision was made over the greatest depth of the mucobuccal fold over the external oblique ridge. Dissection was carried off over the lateral surface of the mandible exposing the lateral surface of the mandible to the posterior border, superiorly to the sigmoid notch and inferiorly around the angle of the mandible.
A Bauer retractor was then placed into the sigmoid notch and a periosteal elevator and J stripper were used to remove the soft tissue from the posterior aspect of the mandible completely. The masseteric sling was elevated off the posterior aspect of the mandible both posteriorly and inferiorly.
At this time, a Merrill retractor was placed along the posterior border of the mandible. At this time, utilizing the oscillating saw and the Stryker, a vertical osteotomy cut was made from the greatest depth of the sigmoid notch superiorly along the posterior border of the mandible to the angle. The osteotomy cut was completed without complication. The inferior alveolar nerve vascular bundle was anterior and medial to the osteotomy cut. The proximal segment was then freed of any medial attachments and then placed lateral to the mandible, and a small moist dressing was placed into the surgical site to protect the proximal and distal segments.
At this time, attention was directed to the left ramus area where similar dissection and similar vertical osteotomy cut was accomplished going from the sigmoid notch superiorly, anteriorly, inferiorly down to the angle. Once again, the proximal segment was elevated lateral to the distal segment, and a periosteal elevator was used to free the medial attachment of the periosteum and muscles to the proximal segment. At this time, the oropharynx was suctioned free of all secretions and debris, and the moist pack was removed from about the endotracheal tube. Previously prepared acrylic splint was then placed over the maxillary dentition, and the mandible was then manipulated into its anatomically determined occlusion and secured by the use of multiple 25-gauge stainless steel wires.
At this time, it was found that the proximal distal segments were well related and that the mandible had been repositioned into its anatomically determined location and secured by the intermaxillary fixation. At this time, attention was directed to the ramus area on both the right and left side. The moist dressings were removed from the surgical site. The proximal segment was found to lie passively on along the lateral aspect of the distal segment. A 1.1 mm wire pass bur was used to make a transosseous hole through the lateral portion of the distal segment through which a 26-gauge wire was placed and passed around the distal aspect of the proximal segment. The proximal segment was then seated firmly within the glenoid fossa and adapted to the lateral aspect of the mandible and secured in place by the use of the transosseous wire. The proximal segment had been well related to the distal segment and was stable with the transosseous wire. Initially, the right side was stabilized first followed by the left side but both were stabilized similarly. We put the 26-gauge wire lapped around the distal aspect of the proximal segment tied to facial aspect of the distal segment.
At this time, it was found that the proximal distal segments were well related and attention was directed to the symphysis area of the mandible. Local anesthetic 2% Xylocaine with 1:100,000 epinephrine had been infiltrated into the symphysis to provide proper hemostasis. Utilizing a #15 Bard-Parker blade, an incision was made in the greatest depth of the buccal mucosal fold going from the right canine to the left canine. Dissection was carried off the inferior symphysis of the mandible to expose the symphysis, going from the mental foramen on the right side to the mental foramen on the left.
Care was taken to protect the mental nerve exiting from the mental foramen. Dissection was carried underneath the inferior border and a small malleable retractor was placed. A 701 fissure bur was then used to make a transosseous hole in the midline both superiorly and inferiorly to the osteotomy cut. Now, utilizing the reciprocating saw, a horizontal osteotomy cut was made approximately 5 mm below the exit of the mental foramen in a horizontal dimension on both the right and left side across the symphysis of the mandible. The horizontal osteotomy was then advanced anteriorly. A few fibers of the genioglossus, geniohyoid needed to be removed for free advancement. A wire pass bur was then used to place three transosseous holes through the buckle cortex of the superior part of the mandible and through the lingual cortex laterally of the horizontal osteotomy segment. A baby awl from an external approach was used to place the circummandibular wire to the midline of the symphysis, which was used to suspend the horizontal osteotomy segment. This was passed transorally. A wire pass bur was then used to pass this hole through the buccal part of the cortex for suspension purposes.
At this time, the horizontal osteotomy segment was advanced to 7 mm as predicted by prediction analysis and was secured by the midline circummandibular wire. The two lateral wires were then tightened to securely stabilize the advanced horizontal osteotomy segment. Care was taken to maintain the symmetry of the horizontal osteotomy segment. At this time, it was found that the horizontal osteotomy segment was well related. The surgical site was then irrigated with copious amounts of sterile water. The muscle closure was then accomplished by the use of interrupted 3-0 chromic suture. Mucosal closure was accomplished by interrupted continuous running 3-0 chromic suture.
Attention was directed to the ramus area on both right and the left side. The area was irrigated with copious amounts of normal saline. A medium Hemovac drain was then placed into the osteotomy sites bilaterally. Mucosa was closed by use of interrupted and continuous running 3-0 chromic suture in a watertight closure. Once this was accomplished, the Hemovac drain was then activated to constant suction. Sponge count and needle count were correct at the termination of the operation. Blood loss for the procedure was approximately 150 mL. The patient was administered 1 gram of Kefzol and 10 mg of dexamethasone at the beginning of the operation. The patient was extubated in the operating room and transferred to the recovery area in stable condition.
