DATE OF OPERATION: MM/DD/YYYY
OPERATIONS PERFORMED:
1. LeFort I maxillary osteotomy.
2. Bilateral sagittal split mandibular ramus osteotomy advancement.
3. Anterior horizontal mandibular osteotomy advancement.
OPERATION IN DETAIL: Following proper identification in the preoperative holding area, the patient was brought into the operating room with an intravenous line in place. The patient was transferred to the operating room table and appropriate monitors were placed. After adequate preoxygenation, the patient was induced to an adequate level of general anesthesia. The eyes were protected and nasal intubation carried out via the right naris without complication. A head wrap was placed, which protected the patient’s forehead from the nasal tube connector and which secured the nasal tube in place for the remainder of the procedure. A Betadine scrub pad was used to disinfect the skin overlying the nasofrontal junction, and approximately 1 mL of 2% lidocaine with 1:100,000 epinephrine was infiltrated in the subcutaneous tissues in this area. To reference the vertical position of the maxilla, a 0.45 K-wire was placed into the nasofrontal junction. The Perkins vertical reference indicator was used to measure the preoperative vertical position of the maxilla. Eight mL of 2% lidocaine with 1:100,000 epinephrine was infiltrated into the maxillary vestibule in the areas of the proposed incisions for maxillary osteotomy. The patient was then prepped and draped in a standard fashion for an orthognathic surgical procedure.
The patient’s oropharynx was thoroughly irrigated and suctioned free of debris, and an oropharyngeal throat pack was placed. Attention was directed to the maxillary vestibule where a full-thickness incision was made utilizing a #15 blade in the mucosa 5 mm superior to the mucogingival junction, from approximately the area superior tooth #3 to that of tooth #14. Adequate superior and inferior reflection of the tissues was carried out to expose the lateral and maxillary walls from the piriform regions to the buttress regions bilaterally. The infraorbital foramina were identified at their inferior extent and the infraorbital nerves were protected bilaterally throughout the remainder of the procedure. The subperiosteal reflection was continued from the buttress regions to the pterygomaxillary junction bilaterally and a toe-out retractor was placed into both sites.
Next, dissection of the nasal mucosa was carried out from the piriform rim region posteriorly along the nasal floor and lateral nasal walls. The preseptal ligament was sharply dissected from the anterior nasal spine. Utilizing a reciprocating saw, with thorough irrigation, osteotomies of the lateral maxillary walls were carried out from the pterygomaxillary junction to the piriform rim regions bilaterally. During this part of the procedure, a ribbon retractor was placed in the piriform rim on both sides to protect the nasal mucosa.
A double safe-sided nasal osteotome was used to separate the nasal septum from the nasal crest of the maxilla, and a single safe-sided osteotome was used to separate the lateral nasal walls. A pterygomaxillary osteotome was used to separate the maxillary tuberosities from the pterygoid plates bilaterally. Using firm digital pressure, the maxilla was gently down-fractured at the LeFort I level. Using the Rowe disimpaction forceps, the maxilla was completely mobilized. Potential bony interferences were removed from the lateral nasal and posterior maxillary walls. The greater palatine arteries were identified and protected, and sharp bony projections arising from the palatine bones were removed. Small tears in the nasal mucosa were repaired using multiple interrupted 4-0 chromic gut sutures.
Approximately 5 mm of the inferoanterior portion of the nasal septum was removed, and a groove was placed along the nasal crest of the maxilla so that the septum could sit passively in its preoperative position. The patient was then placed into the intermediate prefabricated interocclusal splint and into maxillomandibular fixation. Selective bone removal was carried out until the maxilla could be placed into the desired vertical position without interference. A total of four 2.0 mm rigid internal fixation plates were placed bilaterally along the piriform rim and buttress regions. The patient was released from maxillomandibular fixation and it was noted that the occlusion was stable and reproducible into the splint. All surgical sites were irrigated and suctioned free of debris. A 2-0 Prolene alar cinch suture was placed and a 1.0 cm V-to-Y closure of the upper lip midline was carried out utilizing 3-0 chromic gut suture. The midline tissues were carefully reapproximated, and the remainder of the surgical sites in the maxilla were closed utilizing 3-0 chromic gut suture in a continuous horizontal mattress fashion.
Then, 8 mL of 2% lidocaine with 1:100,000 epinephrine was next infiltrated into the mandibular vestibules bilaterally in the areas of the proposed osteotomies. Attention was directed first to the left mandibular vestibule where a #15 blade was used to make an incision in the mucosa beginning at the mid ramus region to a location 5 mm inferior to the mucogingival junction adjacent to tooth #19. The incision was carried down to bone along the left mandibular body in the area of the external oblique ridge. Subperiosteal reflection along the lateral mandibular body was carried out to the inferior mandibular border, and a J-stripper was used to relieve the pterygomandibular sling from the mandibular body and angle regions. An anterior ramus stripper was used along the ascending ramus and the fibers of the temporalis tendon were reflected inferiorly.
Subperiosteal dissection along the medial aspect of the mandibular ramus was accomplished, and a retractor placed to retract the soft tissue superiorly. A nerve hook was used to identify the location of the lingula so that the medial osteotomy could be located accurately. A Seldin retractor was placed along the medial ramus to protect the inferior alveolar nerve. Using a Lindemann bur and a high-speed surgical drill, the medial osteotomy of the mandible was carried out above the lingula and through the medial cortex.
Next, using a #702 bur, an osteotomy of the superior mandibular border was made from the anterior extent of the medial osteotomy along the external oblique ridge, extending anteriorly to the thickest portion of the lateral mandibular body adjacent to tooth #19. This was then connected to a vertical osteotomy that extended to and included the inferior mandibular border. Next, using a series of straight and curved osteotomes, the osteotomies were verified and a Smith inferior border separator was placed into the vertical osteotomy at its inferior extent, and worked gently from anterior to posterior. In this fashion, the sagittal ramus osteotomy was completed on the left side without complications. It was noted that the left inferior alveolar neurovascular bundle was completely encased in the distal segment.
Furthermore, there was no visible trauma to the nerve and it was protected carefully throughout the remainder of the procedure. Potential bony interferences were removed from the osteotomy site and a notch was placed into the proximal segment at its anterior extent to aid in positioning later in the procedure. A moist Ray-Tec was then placed within the osteotomy and attention was directed to the right side where an identical approach to mandibular ramus and body was made. On the right side, it was also noted that the inferior alveolar neurovascular bundle was completely encased within distal segment without visible trauma. Potential bony interferences were removed from the right osteotomy site as well as and a notch was placed for positioning in an identical fashion to the left.
Complete and free movement of the distal segment from the proximal segments was verified and the patient was placed into the final acrylic prefabricated interocclusal splint. Next, she was placed in the maxillomandibular fixation. An incision, approximately 0.4 cm in length, was made just through skin on the right cheek along the lines of relaxed skin tension lateral to the osteotomy site. A trocar assembly was placed via this incision and the proximal segment was positioned so that the condyle was seated in the fossa passively. Three transbuccal 2 mm screws were placed at the superior mandibular border measuring 14 mm and two times 12 mm in length. Attention was then directed to the left side where an identical skin incision was made, and again three 2 mm superior border screws were placed. The patient was released from maxillomandibular fixation, and it was noted that she freely rotated in the splint without occlusal interference.
Attention was then directed to the anterior mandibular vestibule where a #15 blade was used to make a curvilinear incision in the mucosa from the area adjacent to tooth #22 to that of tooth #27. This incision was connected to the anterior extents of pre-existing ramus osteotomy incisions bilaterally. Both the right and left sides, the mental nerves were identified and protected throughout the remainder of the procedure. The mentalis muscle was transected down to the level of the bony anterior mandible and subperiosteal dissection was carried out in the area of the symphysis and continued posteriorly along the inferior mandibular border to a point inferior to and proximal to the mental foramina bilaterally. Care was taken to preserve the attachment of the mentalis muscle to the most distal portion of the symphysis to ensure adequate blood supply to that area following the osteotomy. The chin midline was marked and the inferior extent of the mandibular canine was marked bilaterally.
Next, an anterior horizontal mandibular osteotomy was carried out from left to right utilizing a reciprocating saw without complication. This osteotomy was completed 5 mm inferior to both of the mental foramina and the root apices of the mandibular canine teeth. An 8 mm OsteoMed chin plate was used to achieve advancement of the distal anterior mandibular segment and the plate was secured with a total of four 2.0 x 6 mm screws. Next, using a total of three 3-0 Vicryl sutures, the mentalis muscle fibers were carefully approximated to the original position.
The remaining surgical sites were thoroughly irrigated and suctioned free of debris. The mandibular surgical sites were reapproximated using 3-0 chromic gut suture in a continuous interlocking fashion. The patient’s oropharynx was suctioned, irrigated, and oropharyngeal throat pack was removed. Multiple white dental elastics were placed to guide the patient into the splint and the K-wire was removed from the area of the nasofrontal junction. The extraoral incisions were closed with 6-0 Prolene suture and each was covered with an elastic bandage. A chin dressing was placed consisting of two strips of 1 inch foam tape and a head wrap was placed with pressure gauze placed extraorally over the surgical areas. Care of the patient was then turned back to the anesthesia team. The patient was extubated in the operating room without difficulty and transported to the postanesthesia recovery area in stable condition with spontaneous respirations, having tolerated the procedure well without known surgical or anesthetic complications. The patient’s estimated blood loss was 200 mL and urine output level 1100 mL.
OPERATIONS PERFORMED:
1. LeFort I maxillary osteotomy.
2. Bilateral sagittal split mandibular ramus osteotomy advancement.
3. Anterior horizontal mandibular osteotomy advancement.
OPERATION IN DETAIL: Following proper identification in the preoperative holding area, the patient was brought into the operating room with an intravenous line in place. The patient was transferred to the operating room table and appropriate monitors were placed. After adequate preoxygenation, the patient was induced to an adequate level of general anesthesia. The eyes were protected and nasal intubation carried out via the right naris without complication. A head wrap was placed, which protected the patient’s forehead from the nasal tube connector and which secured the nasal tube in place for the remainder of the procedure. A Betadine scrub pad was used to disinfect the skin overlying the nasofrontal junction, and approximately 1 mL of 2% lidocaine with 1:100,000 epinephrine was infiltrated in the subcutaneous tissues in this area. To reference the vertical position of the maxilla, a 0.45 K-wire was placed into the nasofrontal junction. The Perkins vertical reference indicator was used to measure the preoperative vertical position of the maxilla. Eight mL of 2% lidocaine with 1:100,000 epinephrine was infiltrated into the maxillary vestibule in the areas of the proposed incisions for maxillary osteotomy. The patient was then prepped and draped in a standard fashion for an orthognathic surgical procedure.
The patient’s oropharynx was thoroughly irrigated and suctioned free of debris, and an oropharyngeal throat pack was placed. Attention was directed to the maxillary vestibule where a full-thickness incision was made utilizing a #15 blade in the mucosa 5 mm superior to the mucogingival junction, from approximately the area superior tooth #3 to that of tooth #14. Adequate superior and inferior reflection of the tissues was carried out to expose the lateral and maxillary walls from the piriform regions to the buttress regions bilaterally. The infraorbital foramina were identified at their inferior extent and the infraorbital nerves were protected bilaterally throughout the remainder of the procedure. The subperiosteal reflection was continued from the buttress regions to the pterygomaxillary junction bilaterally and a toe-out retractor was placed into both sites.
Next, dissection of the nasal mucosa was carried out from the piriform rim region posteriorly along the nasal floor and lateral nasal walls. The preseptal ligament was sharply dissected from the anterior nasal spine. Utilizing a reciprocating saw, with thorough irrigation, osteotomies of the lateral maxillary walls were carried out from the pterygomaxillary junction to the piriform rim regions bilaterally. During this part of the procedure, a ribbon retractor was placed in the piriform rim on both sides to protect the nasal mucosa.
A double safe-sided nasal osteotome was used to separate the nasal septum from the nasal crest of the maxilla, and a single safe-sided osteotome was used to separate the lateral nasal walls. A pterygomaxillary osteotome was used to separate the maxillary tuberosities from the pterygoid plates bilaterally. Using firm digital pressure, the maxilla was gently down-fractured at the LeFort I level. Using the Rowe disimpaction forceps, the maxilla was completely mobilized. Potential bony interferences were removed from the lateral nasal and posterior maxillary walls. The greater palatine arteries were identified and protected, and sharp bony projections arising from the palatine bones were removed. Small tears in the nasal mucosa were repaired using multiple interrupted 4-0 chromic gut sutures.
Approximately 5 mm of the inferoanterior portion of the nasal septum was removed, and a groove was placed along the nasal crest of the maxilla so that the septum could sit passively in its preoperative position. The patient was then placed into the intermediate prefabricated interocclusal splint and into maxillomandibular fixation. Selective bone removal was carried out until the maxilla could be placed into the desired vertical position without interference. A total of four 2.0 mm rigid internal fixation plates were placed bilaterally along the piriform rim and buttress regions. The patient was released from maxillomandibular fixation and it was noted that the occlusion was stable and reproducible into the splint. All surgical sites were irrigated and suctioned free of debris. A 2-0 Prolene alar cinch suture was placed and a 1.0 cm V-to-Y closure of the upper lip midline was carried out utilizing 3-0 chromic gut suture. The midline tissues were carefully reapproximated, and the remainder of the surgical sites in the maxilla were closed utilizing 3-0 chromic gut suture in a continuous horizontal mattress fashion.
Then, 8 mL of 2% lidocaine with 1:100,000 epinephrine was next infiltrated into the mandibular vestibules bilaterally in the areas of the proposed osteotomies. Attention was directed first to the left mandibular vestibule where a #15 blade was used to make an incision in the mucosa beginning at the mid ramus region to a location 5 mm inferior to the mucogingival junction adjacent to tooth #19. The incision was carried down to bone along the left mandibular body in the area of the external oblique ridge. Subperiosteal reflection along the lateral mandibular body was carried out to the inferior mandibular border, and a J-stripper was used to relieve the pterygomandibular sling from the mandibular body and angle regions. An anterior ramus stripper was used along the ascending ramus and the fibers of the temporalis tendon were reflected inferiorly.
Subperiosteal dissection along the medial aspect of the mandibular ramus was accomplished, and a retractor placed to retract the soft tissue superiorly. A nerve hook was used to identify the location of the lingula so that the medial osteotomy could be located accurately. A Seldin retractor was placed along the medial ramus to protect the inferior alveolar nerve. Using a Lindemann bur and a high-speed surgical drill, the medial osteotomy of the mandible was carried out above the lingula and through the medial cortex.
Next, using a #702 bur, an osteotomy of the superior mandibular border was made from the anterior extent of the medial osteotomy along the external oblique ridge, extending anteriorly to the thickest portion of the lateral mandibular body adjacent to tooth #19. This was then connected to a vertical osteotomy that extended to and included the inferior mandibular border. Next, using a series of straight and curved osteotomes, the osteotomies were verified and a Smith inferior border separator was placed into the vertical osteotomy at its inferior extent, and worked gently from anterior to posterior. In this fashion, the sagittal ramus osteotomy was completed on the left side without complications. It was noted that the left inferior alveolar neurovascular bundle was completely encased in the distal segment.
Furthermore, there was no visible trauma to the nerve and it was protected carefully throughout the remainder of the procedure. Potential bony interferences were removed from the osteotomy site and a notch was placed into the proximal segment at its anterior extent to aid in positioning later in the procedure. A moist Ray-Tec was then placed within the osteotomy and attention was directed to the right side where an identical approach to mandibular ramus and body was made. On the right side, it was also noted that the inferior alveolar neurovascular bundle was completely encased within distal segment without visible trauma. Potential bony interferences were removed from the right osteotomy site as well as and a notch was placed for positioning in an identical fashion to the left.
Complete and free movement of the distal segment from the proximal segments was verified and the patient was placed into the final acrylic prefabricated interocclusal splint. Next, she was placed in the maxillomandibular fixation. An incision, approximately 0.4 cm in length, was made just through skin on the right cheek along the lines of relaxed skin tension lateral to the osteotomy site. A trocar assembly was placed via this incision and the proximal segment was positioned so that the condyle was seated in the fossa passively. Three transbuccal 2 mm screws were placed at the superior mandibular border measuring 14 mm and two times 12 mm in length. Attention was then directed to the left side where an identical skin incision was made, and again three 2 mm superior border screws were placed. The patient was released from maxillomandibular fixation, and it was noted that she freely rotated in the splint without occlusal interference.
Attention was then directed to the anterior mandibular vestibule where a #15 blade was used to make a curvilinear incision in the mucosa from the area adjacent to tooth #22 to that of tooth #27. This incision was connected to the anterior extents of pre-existing ramus osteotomy incisions bilaterally. Both the right and left sides, the mental nerves were identified and protected throughout the remainder of the procedure. The mentalis muscle was transected down to the level of the bony anterior mandible and subperiosteal dissection was carried out in the area of the symphysis and continued posteriorly along the inferior mandibular border to a point inferior to and proximal to the mental foramina bilaterally. Care was taken to preserve the attachment of the mentalis muscle to the most distal portion of the symphysis to ensure adequate blood supply to that area following the osteotomy. The chin midline was marked and the inferior extent of the mandibular canine was marked bilaterally.
Next, an anterior horizontal mandibular osteotomy was carried out from left to right utilizing a reciprocating saw without complication. This osteotomy was completed 5 mm inferior to both of the mental foramina and the root apices of the mandibular canine teeth. An 8 mm OsteoMed chin plate was used to achieve advancement of the distal anterior mandibular segment and the plate was secured with a total of four 2.0 x 6 mm screws. Next, using a total of three 3-0 Vicryl sutures, the mentalis muscle fibers were carefully approximated to the original position.
The remaining surgical sites were thoroughly irrigated and suctioned free of debris. The mandibular surgical sites were reapproximated using 3-0 chromic gut suture in a continuous interlocking fashion. The patient’s oropharynx was suctioned, irrigated, and oropharyngeal throat pack was removed. Multiple white dental elastics were placed to guide the patient into the splint and the K-wire was removed from the area of the nasofrontal junction. The extraoral incisions were closed with 6-0 Prolene suture and each was covered with an elastic bandage. A chin dressing was placed consisting of two strips of 1 inch foam tape and a head wrap was placed with pressure gauze placed extraorally over the surgical areas. Care of the patient was then turned back to the anesthesia team. The patient was extubated in the operating room without difficulty and transported to the postanesthesia recovery area in stable condition with spontaneous respirations, having tolerated the procedure well without known surgical or anesthetic complications. The patient’s estimated blood loss was 200 mL and urine output level 1100 mL.
