Open Reduction and Internal Fixation of Mandibular Body and Parasymphyseal Fractures with Maxillomandibular Fixation and Broken Tooth Extraction

CHAPTER 1

Hi, I am Dr. Thomas Lee from Virginia Commonwealth University. Today, I'd like to discuss a patient who had a motor vehicle accident and suffered a mandible fracture. We'll start out by discussing patient's CT imaging. So this particular patient you can see has a fracture involving the parasymphysis and what's interesting is this particular patient does have canine fracture that has split across and this will be addressed during surgery. Similarly, on the opposite side, patient has a body fracture. In this case, the outer cortex is in two separate fracture segments. So you have one, two, and three segment piece with two inner cortex that's involved. And this also will require reduction and fixation. And because it's telescoped with this middle piece, I anticipate this being more difficult to reduce, especially because it's in three pieces. Here you can see the canine with the roots present, but the crown is gone, with the parasymphysis fracture and the body fracture starting here with the telescoped middle piece. And here is your 3D reconstruction, showing what we just discussed, parasymphysis fracture and the body fracture. The key surgical steps involve putting the patient to sleep using nasotracheal intubation. This way the endotracheal tube will not interfere with restoring patient's premorbid occlusion. Once patient's asleep, we'll start with the prepping and draping in a sterile fashion. The first step with the surgery involves exposing the fracture site for the both parasymphysis and the body fracture will begin with intraoral incision. Once both fracture sites's exposed, I'll generally focus on the easier fracture, in this case, is the parasymphysis fracture site. Now this area, to my surprise, had a fracture involving the tooth roots. In consultation with the oral maxillofacial surgeons, they recommended that we proceed with extraction of the tooth. In this case, we used drill to remove remaining tooth roots. Unfortunately, they were not available to come in, so this was the best option that we had at the time. Once the tooth root was addressed involving the parasymphysis, we then focused on bringing the patient into proper bony reduction. We performed maxillomandibular fixation using IMF screws, bringing patient into premorbid occlusion. Once patient was in rigid MMF, we then proceeded with fixation process. For the parasymphysis, we used mini plates with mono cortical screws along the top and bicortical screws along the inferior plate. For the body fracture site, we used a hybrid plate that has essentially two plates that are fused side by side. The benefit of this is that you have both superior and inferior plate in a very limited space. And we were able to fixate this area once it was properly reduced. For the anterior screws, we were able to place screws through the intraoral approach. For the posterior area, we had to use transbuccal trocar approach to place the screws in a proper alignment. Once the body fracture was properly fixated, we then proceeded with closing. Because patient has significant mucosal injuries, our goal was to perform watertight closing of the mucosal lacerations. Once that was completed, we emptied out gastric content to ensure the patient does not vomit from any blood that the patient may have swallowed. And at that point we had concluded the procedure and patient was safely extubated.

CHAPTER 2

So the way we're gonna position the patient, we usually turn 90 degrees away from the anesthesia. We go past 90. So we'll have access through all three sides. And I generally will always also almost always prefer to do nasotracheal intubation like this with a tape at the top to secure it to prevent it from coming out. And I generally use paint and I'll actually dunk this in the mouth 'cause we want to make sure mouth gets sterilized as much as possible. And we will prep the whole face out. And especially for a patient like this, we have bilateral fracture. We want to have access to both sides of the face. And just in case we also need an external approach, we'll also prep out the neck. So the whole prep should include bilateral face and neck. And whenever you're prepping around the face, best to avoid using scrub 'cause it will be very irritating to the eyes. Just use paint, and in this case I come right up to the, at least up to the level of the cheekbone so that we'll have full exposure without anything interfering our surgical field. And then now we're ready to drape. Alright, so we'll usually put blue scrunches on both sides of the neck and then we'll use straight piece like this. We will call them off around like a square. I do want to be able to see the neckline in case we have to go externally. Okay. So then we'll secure these. Okay, alright. Do you have a split drape? Lovely. Okay. Put it right up to here. Now that go straight down, the head drape please. Perfect. Goes right here. Okay, let's do timeout. We are doing RF of mandible, bilateral maxillomandibular fixation, risk of fire high, any antibiotics? Great. Can I get a tulip retractor? Just for occlusion.

So we're gonna start by putting a tulip retractor. You have a Frazier suction? You see that patient already has maybe even a missing tooth here. So some injuries and very gross malocclusion - irrigate. Stop, hm mm. Just an open fracture with the gingiva disrupted right where the fracture is present. So we'll first begin with the approach here. We're gonna see the nerve right in this location. I want to preserve it. And also I'm thinking about how we're gonna close this mucosa later. Can I get a DeBakey. There's bone. I'm gonna remove it so that we don't have an airway foreign body later. I'm not sure what this is. Might be... Might be missing teeth. Yeah, hmm. There might be teeth broken out. Yeah. So we're just trying to figure out how we're gonna close this later. This has to be closed in a watertight fashion. Do you have number nine, please? Just want to investigate this area before we commit to any particular incision. Suction that out please, there's more bone. I'm gonna remove all these debris because these are potential for airway foreign body. Yeah, I think her canine is broke. The canine is completely broken off. Makes me wonder if this is the canine. Suction for me. Yeah. That's her tooth root, right there. Hmm. It's a broken tooth. The roots are obviously disrupted. Also look like there might be old dental caries here. Can I have some irrigation? Yeah. So generally if the root is broken like this, we want to remove it because the dead tooth is a potential for infection in the future. I think that might be part of the tooth. The downside of removing it now is that it'll create a bone gap. So we'll have a harder time reducing it. It will lack stability because there'll be a bone gap. Another option is just plate it and then construct it in a separate situation. So looking at that, I think the, let me get a Bovie.

CHAPTER 3

We are gonna make an incision but I need to close this, meaning I need to figure out a way to close it in a watertight fashion later. We have enough mucosal stuff to close, along the lingual aspect. This might have to bend in to close this area. We make an incision here. Debating if I connect it or leave it separate. I'm gonna lean towards leaving it separate for now. Do you have iris scissors? Yeah look for our nerve as we go down. Should be right by the premolar. There it is. There's your nerve. Here's your nerve coming out, coming superficially. We're gonna preserve that. Yeah, go ahead, Bovie. I'm gonna cut away from this nerve, go ahead. Take this out. Do you have a retractor like a smaller one than that? Yeah. Yeah, will you hold this up for me? Because I wonder if it needs to be extracted. Which one? This canine, it's split right down the middle. I think this is the remaining part of the canine. There's a caries and stuff, so I think it's split off. But ask them if they would recommend leaving it or just extracting it. So there's your nerve. We're gonna cut down here. We know the nerve is over on that side. Suction. I see the nerve. Nerve is coming and entering the skin there. Now that we know where the nerve is from the midline, I can go subperiosteal, come straight down. This is right where the fracture site is. Do you have any 1% lido with epi? Sure do. Notice that it's a little bit oozy, so in this case I'll go ahead and inject it to see if we can get better hemostasis as we perform the rest of the surgery. At this time I've asked our oral maxillofascial surgeon to come by and take a look at the teeth to see if they prefer to check it now or later. I can reduce it and plate it however they prefer. Patient most likely will need this extracted. Wanna see what their preference to do in terms of timing. Number nine, please. Now here we're gonna dissect all the way down through the inferior border. Number nine, please. We're gonna dissect all the way down to the subperiosteal tissue plane to the inferior border of the mandible here. For this type of fracture, I always like to see the inferior border because that's one of our visual reference that tells us we have adequate reduction or not, come in with the retractor. Do you have it going the other way? So my goal is to expose enough soft tissue and bones so that this retractor that I have with toe going the other way and hook under can actually help with the exposure as well as the reduction. So there's our fracture line. Let's put a plate here, another one here. Can I get a number nine. I saw them there come up, I want to see the foramen just to help me decide exactly where to put the plate there. Right there. Bovie. Yeah. I wonder, yep, that's fine. So there's your bone. And even though this fracture is only about a day old, there is already callous forming. I generally like to scrape all this, especially if it's an old fracture, as it will interfere with our reduction process. There's your nerve. The question is, is there enough for two holes on this side? So you want to expose the bone enough so that we can put at least two holes on both sides of the fractures. This is sort of how the bone should come together. Just wanna figure out this tooth situation. I have a feeling the response from oral surgery team might be too extract the tooth. Do we have a dental extraction set? We do. We made sure it was in the room. Can I look at it? Yeah. Looks like the tooth has split. Let me get a local while we wait. Unprotected needle. Okay. Needle coming in. Suction there, yeah suction suction. And then inject right where we're gonna make the incision. Just inject where the incision will be made. Just a couple millimeters away from the gingival sulcus and then I go subperiosteal, inject right down to the level of the bone. Okay, alright, come on out with that. You have a tulip back, please? Okay, let's see what you have. There should be a little sharp triangular pointy things. This thing? Yes, let me get that. I can use that. Alright, so I'm gonna see if I can wedge this in here. Wedge there. See if there's a wedge in there, sharp and pointy things. Here's another sharp and triangular one. That's it, yep. And I do wanna preserve the mucosa. But the tooth has to come out. Can I get number nine, please? Suction right here. There you go. There is the remaining mucosa. Can I see the triangular tool again? Best option is to use a drill.

So we're gonna start occluding this while we are waiting. This incision from here to here, you don't wanna make it too wide 'cause it actually will block your point of view. Then the nerve's gonna be right by the first and second premolar. Can I get a number - iris scissors, first? We should be behind the nerve. There is your nerve coming out right there. Right between the first and second premolar right there. Grab the Bovie. Okay, open this, right there. Just Bovie right there. Good. Once I know where the nerve is. Do you have a toe in retractor that I was using earlier? The residents aren't around right now, but they looked at the scan and they think you should probably just take it out. Yeah, right? From how it looks on the scan. Okay, I'll take it out. That's fine. Curve it back this way. Now cut right down. Here's your fracture right there. There's your nerve. Okay, now come out with this. Turn the head. Okay, there's your nerve. Okay, you have a longer toe in? And it's a 702 drill bit. Let me get a number nine retractor. I'm gonna use number nine. Suction. So this one you can already see the inferior border. I can see the fracture, that we are gonna advance forward. Find this other section of this fracture. Suction. Some irrigation in there, there's the fracture. One more retractor, that's good. Thank you. There is your fracture line. Gonna clean it, with a Bovie. The nerve is in front of us. Go down to the inferior border. Okay, number nine, again. Thank you. Iris back, please, iris scissors. I have to dissect this nerve out because I need to see the superior border. There is your nerve right there, coming out. Bovie. Number nine, please. You have the one going the other way? The long toe out? You can see where the fracture is. I'd like to see both ends and also like to see where the nerve comes out. So we know how much room there is for the plates to sit. The nerve is being swept forward. Still have not seen the foramen. All right, so we're... The nerve is in here. Have more than enough exposure. Okay, hold on with this. Hold this. Don't block my vision. I wanted to see that nerve for sure. It's gonna be more anterior, can this wrench come up? I just want see the whole stump come out there. There it is. Yeah, we're far away from the nerve. Can I get some irrigation, please. Irrigations please. Okay, let me know when that drill bit, oh you got it. Your drill will be ready. Alright. And does that look like the side cutter that you... Okay, great. Yeah. Okay, let me see the tulip back, please. Okay, come on on with this.

CHAPTER 4

Okay, so the first step right now we got everything exposed. Now because the tooth is completely broken at the root level, the best idea is to remove the whole thing because the dead root will get infected. Number nine, please. Let's do that because the edge we had left it has split away. Yeah, we have to make the incision with understanding how we're gonna curve it. At this point, we will remove this tooth that's obviously broken off. It's very impacted, so it's not coming out. Look like there's some carries on the back in this location. Grab the irrigation. So this is a side cutting burr. Drill right into this. Hold on, too big. I'm gonna cut this pieces off. Okay. A little bit more, yep. Just gonna drill right into this area. Make sure all the remaining tooth root is gone. Gotta make sure we don't disrupt the tooth that the bases touch. Hmm, irrigate. Yeah it looks good to me. I think there might be a little bit of tooth. Number nine, please. I just make sure there's no remaining tooth on this side. Maybe a hint of it left right there. Oh yeah, I think there's nothing in here. I think the tooth already came up from this side. Just smooth it out. Okay good, so the tooth is gone. Number nine, please. So that now the chance of this getting infected is significantly reduced. Suction, suction. Come on out, yep. I think there's still tooth left in there. Tooth left in there. Yep, there's tooth left in there. Yeah. There we go. Hm, yeah. That's better. Now there's callous formation since the accident. Take this back. Okay. I just wanna make sure all the tooth is gone. The DeBakey, please. Hold on. So the tooth is good on that side.

CHAPTER 5

We are next gonna put her back into, proper occlusion. Is our next step. Now to do that we're gonna do maxillomandibular fixation. So the next step is we are gonna do maxillomandibular fixation here. Can I get the IMF screws? And this bite, let me do eight, please. So by doing so, we will put her back into proper occlusion. So that kind of look like premorbid occlusion. Thank you. So we are gonna secure probably one on this side, one on this side. How many are we gonna use? Maybe one on this side. Maybe four to six. Okay. That's an eight. Yeah. When you fix this, you wanna make sure you do not hit the tooth roots. I'm aiming for space in between the tooth roots. That is too close. It's not secured properly. Suction right here. Go right in there. I wanna make sure we do not hit the tooth roots by assuming there's twice to the root height, twice as the height of the crown. One more, please. So we're gonna put next screw adjacent or on the maxillary counterpart of that, that will bring her into proper occlusion. The maxilla, if you go too high, it'll be anterior maxillary sinus wall bone, which is super thin. So I wanna catch the thicker part of the alveolar bone, if possible. I am using this as a temporary reduction. If I were to leave this patient in MMF, which I typically do not for non-comminuted fracture like this. But if I were to leave long term, four to six weeks of MMF, I would recommend using arch bar type of MMF because these screws have a tendency to come out and there's a potential for it to be an airway foreign body. So it's fine for intra-op but not, I prefer not to use them for long term. But these screws can come out is the issue. Center incisors there, go right between the tooth roots. You can see that central segment is completely mobile. So that will go to this one. Now this back one, see where the bone is. Get some irrigation. Do you have a long pull out? And do you have one more long toe in? Hook this along the side of your border, then sideways. Okay, hold that please. Okay. I can see the fracture down there. Okay. I think they need to line up. Yep that and that lines up. It's how it looks to me. Come on out with this for a second, yep. Telescoped in, this and this needs to overlap. Yeah. So that's sort of how it should fit. Okay, alright. So we will want to secure one little bit more posteriorly. Be nice to have one more on this, but there's not much bone left on the posterior segment. Okay, can you get those wires? Gonna start with this segment because everything is so loose. Okay. Yep. So these wires line up with the slot, the screws, the screwdriver, how it engages. This crisscross lines up with the wire holes. I'm gonna first tighten this so you can kind of pull on it first. Make sure there's no significant laxity but as I'm twisting I'm not pulling on the wire 'cause it could snap. These wires are sharp, so you gotta be mindful of that. You don't want to get sharp injuries. I'm looking at this here. Irrigation, please. Yeah. Looks like we're missing a little bit of... Go on, on this side. I think this is that cortical bone that was, we're seeing, please save that. Although I don't think that's very usable. That's the outer cortex bone. So, good contact up here, superiorly. Inferior looks okay, so there's decent bone here. You could make the argument to put a recon bar. There's a little bit of gap, I think that's a little bit excessive. So in this case, this person is fairly young, 21-year-old. So I think they will do fine with just the regular mini plates. I think it would be okay. Might want to use a six-hole plate instead of four-hole plates. Okay, so that looks good. Can I get a wire cutter? Here is this back. Can I get a needle driver? So I always wanna, think this is a little bit long. Can I get the wire cutter back, please? These are potential for sharp injuries. So I grab it, I'm gonna twist it, I'm gonna pinch it and make sure it points away from us so it does not come back and get us. Okay, let's see this side. The goal is to get the teeth lined up. Because teeth are very sensitive to malocclusion, in the sense that even if you have a floss stuck between your teeth, pin number nine, please, your body can tell that there's floss stuck there. So even a little bit of gap will bother them since that sensation of malocclusion will be bothersome. So can you suction right there? Okay, good. Okay, pretty happy with that. Let's do wires again. Do one more set of wires. Front to back. Give it a little bit of a tug. Wire cutter. Twist it. Now when you're tightening it, don't pull 'cause it'll snap. Okay, let's cut it right below me. Yep, go ahead. Put your wire down. Sarps down. I'm gonna grab it, twist it and then pinch it. Make sure it's pointing away from our gloves.

CHAPTER 6

Okay, so the key to stabilizing this, just start with the easier one and go to the harder one. And in this case this posterior body fracture is gonna be harder of the two. So we're gonna start with this one. The reason why you want to do the easier one first is if you have an error, that will compound. So you always wanna get your first reduction and subsequent ones to be as close to perfection as you can. So let's see the toe out retractors. There it is. What is this? What's the name of this? That's reduction forceps. Just reduction forceps, okay. So I use this and then, so we'll use this to reduce it. You can use a bone reduction forceps like this or like this. You don't want to put it this way 'cause it's gonna block all of our plating. So I want to put it like this. Awesome. And the other thing I might do here, as I'm having a hard time seeing, just gonna extend the incision. Just straight down. The nerves are well away from us. Number nine elevators, coming down. You have a toe out retractor, please? That's the long one, you want shorter? Get one a little bit shorter than that, please. Okay, there's the midsize. That, we'll see if you can get the tulip in. But normally we get this out but that actually looks pretty reasonable. Can I get an irrigation? You can see there's a fair amount of gap still. Okay. Here you can see the inferior alveolar nerve coming out. Here's your gap. Before we move forward, I'll make sure that the teeth are well aligned with good contact of where this sits bilaterally. This piece we will worry about later, but at least in the front it looks good. And we are gonna now focus on where we're gonna put the plates. And so I'll probably put a plate here, another plate here. The top plates, I'll use monocortical to avoid the tooth roots. Lower one, you can go bicortical if you like. I'll always like to use all my screws to be locking screws. That way if there's any bit of issue with plaque adaptation, it will compensate and still provide good stability. So first just say we're gonna put the plate here. We might put a plate up here. And the question is, where can I safely drill. The tooth root might come down to about this area. So I wanna make sure we're not close to the tooth roots. And this bone clamp we can remove it after the first plate goes in. Use number nine to kind of fulcrum and get it into right alignment. And we are gonna fine tune that in a second with this bone clamp. So my thought is get it reduced with the bone clamp and then put a plate on and then we'll remove the bone clamp. So I'm gonna be liberal with where I'm gonna put this, generally nice to just put it where it won't be in our way. So I'm gonna put it about - we want to be sufficiently away so we can close this gap. I see a gap here so I might put it right here. Okay. And then we're, don't want to drill next to the nerve. So drill about here. Irrigation. Irrigate. Okay, you got the bone clamp? Let's say you wanna put it towards the right direction here. One goes in on that side, the other one goes on this side. I can wiggle this and kind of get it into the right alignment. Okay. Looking better. Okay, that looks pretty good to me. Irrigation again. So that reduces it to a tighter alignment. Checking the inferior border - suction. All the way down there. So make sure the inferior border gets lined up. Hold this like so. That's pretty good. Okay. Yeah, looks good. So the next thing is we will proceed with the four-hole plate for this. The bone on both sides of the fracture line is very healthy looking. There's good bone stock. So let me use a, yeah this one with a little bridge. Are you doing inferior first? Yep. - Yeah, so in this case the parasymphysis, biomechanically speaking, the inferior border is where it would splay. So the inferior plate is the more important one. Some authors, some surgeons might prefer to use thicker just a single thicker plate here, that's fine too. In this case I'm gonna just use two small mini plates. It's pretty adequate. So in this case I'm using a rainbow, long bicortical screws is probably what I'll end up using. The first two screws are the most important. Irrigation. I wanna make sure - can I see number nine for a second? I wanna make sure that posterior hole, you have enough bone there to secure. That looks good. Okay, screw. Gonna start drilling. That's fine, irrigate, irrigate. Okay so as I'm drilling, I'm feeling for first pop is the inner cortex. That's the second pop, that's the second one. That was inner cortex. Can I see the - do you have a screw depth gauge? I'll just measure one just to kind of give us an idea as to how deep this is. But I'll generally use about eights, eights or tens in this area along the inferior border. So there's a little hook. The idea is you put it through the hole and you catch it, the backside side, you push it down and it says 10. Can I get a 10 locking please? Yep, 10 locking. Alright, confirm with 2.0 10 locking. Lovely goes in. Now this first one, I'm not gonna tighten it all the way, I'm just going to secure it so that it partially engaged. This allows me to move my plate in the second hole, and this is really the key screw here. So then I make sure that we're happy with this alignment. This alignment looks good on both sides. Next hole. And when you do this, you wanna make sure you don't cut on the lip. This drill can slice through the lip. Going perpendicular to the bone surface. First pop, second pop. Can I get a 10-millimeter screws? So 10? Yep. So the locking screws has threads right there. That's what will lock onto the plate, give us extra stability. If there's any bone gap from the plate to the plate, we'll stabilize it. With non-locking screws, you won't have that luxury. You have to be perfectly adapted to the plate. So these locking screws, yes they cost more but I think they save a lot of time in the OR and I think they just provide superior stability. So there we go. So I'm gonna just take this off 'cause we, I'm pretty certain that that was enough. So we are then gonna proceed with the rest of the drilling and screw placement. Irrigation. This back one, this is the one that's a little bit harder. There you go. Coming at a little bit of an angle here again be another advantage of this is angle, when you drill this at an angle, depending on the manufacturer, it allows for 30 degrees of movement or angulation. Just still the screws. Still provide it should be able to still lock on even if it doesn't come in at a perfect angulation. That feels solid. One more please, one more drill. Irrigation. Going down perpendicular to the bone surface. First pop, second pop. 10 millimeter. And if you're really worried you can measure all the screw length. But they'll generally not deviate much in someone like this with teeth. So usually not necessary. In this case, screw likely is caught up by bone dust. In that case you're gonna come out to or come out once, go forward, come out once, go forward, come out once go forward that will just clear the bone dust so that it can engage to the plate properly. All right, so that was our first plate. Generally I would prefer to put two. That's showing good signs of reduction there. Can I see another four-hole, maybe without a bridge this time, please? Thank you, thank you. You're welcome. Alright so this we're lucky in the sense that this area, we're right in front of the nerve, we're not near the nerve. The nerve is there. You need to sometimes go above it or right below it. But in this case we have the luxury of not worrying about that too much. It looks like the front and the back plate needs to be bent down a little bit. Can I get a plate bender? So these mini plates, you could potentially bend it with your fingers but we use a small plate bender like this 'cause that last plate, last plate screw holes needs to be bent down just a teeny bit. And it's generally better to just do one at a time 'cause there's a general tendency is to bend it too much and then it doesn't quite fit. That looks better. Now the superior plate, I wanna make sure I don't go into that hole there. Oops sorry. Right there and right there. Yeah, that's good. Okay, can I get the drill back, please? So these, I'm gonna go monocortical. These are the smaller ones. Great, thank you. What are the - is this five stop, or what are the? That's a five stop. Oh, lovely. The five millimeter, yep. There's your one, two going in. Again, partly, part of the way in. And then we move this plate over. Yep, right there. There you go. Leave it to where I wanted to. And for the superior plate I like to use either four- or five-millimeter screws. Especially if I'm getting really close to the tooth root, so I wanna make sure I don't put it through the tooth roots. Tighten the first one, then go back, tighten the second one. Feels solid. Then these holes look very well adapted already. So point it perpendicular to the bone. Irrigation, please. Hm, mm. Let it start and then come down. Okay. One more, irrigation, hm mm. It's okay, all right. Screw. Alright, keep it on at the angle where I'm at on this side. Do you have another screw? Yep, and here's another five. Yep. Here, go down. Yep, go all the way down. A little bit more. That's it, perfect. So we're good on this side.

So we're gonna start looking at this section. This is that posterior body segment that was quite telescoped, but you can see that the - you guys see number nine, please? Yeah you can see this part. See the outer cortex part that had greensticked. That looks like... It's kind of a greenstick fracture right there. Yeah, I think it's properly reduced... So part of it might be the greenstick fracture that's giving us the problem. That's better. I kind of like that. Irrigation. And the teeth is now in posterior, and push up like that. Yeah so it needs to be like this while we're plating. This area also needs to be pushed a little bit more. You got a long toe out? I'm sorry. I'll turn her head. Ideally, like to see the inferior border. Let me see one more toe in retractor. Tough to see an angled fracture. Let me see this way, with toe out. You have a Bovie? Then if your border needs to be looked at more closely here. Trying to avoid opening this. That looks better. I think that's how it should be, just like that. Okay. It's a little bit tricky. The back one needs to go all the way back here. Come down. The upper one's straightforward. The upper one is okay, question in mind that I have is do I do two separate plates or one hybrid fused plate. But generally we'll do two plates but this is a little bit of unusual fracture. Okay, now the other thing I noticed is a little bit more exposure anteriorly. With the body there's a cordial movement where the bone is instead of splaying superiorly or inferiorly, it has more of a side to side movement. Okay, so that's kind of how I want it to be when I reduce this. Teeth are not quite touching on the back side, I think, yeah, that would be good. Like so, just like so. What I'm noticing is little bit of open bite posteriorly. I might put little bit more - another IMF screws. Pull it up. Let me get two more IMF screws, please? The one that we were using before? And one option is to use this type of plating system. This is what I typically use on the angle area. This might be an option. Give us a fair amount of flexibility. That might be an option. Okay, so we'll first do this 'cause I don't want this area to stay open. If I really want I can put another one back there but it's gonna be hard to reach back there so I'm not going to try to attempt to do that. But that is another option. It's just that it's gonna be limited space. Go right here. Pull this. Can I get the wires next please? Yep. Awesome. That's it. Pull it through. So by doing that I can see that the back segment is closing down, which is ideal to avoid open bite deformity. Yeah, do you have the wires again? The wire cutter rather. Yeah. Hm, yep. Do you have one more blue towel? Point this way, close it. You have stapler or, this one's good, thank you. Okay and then now we're gonna start plating this. This is a lot more stable posterior. Actually the posterior segment also looks very stable. Question here is, I should be able to plate all this through the mouth. Another option is go transbuccal here. Let's see that nerve one more time. There is a way out here, yep, that's the foramen right here in line with the premolars. So we're well away from that. So the plate configuration is the next decision that we have to decide on. It looks fairly well reduced, actually. Just releasing a bit of it more posteriorly for us to get better exposure. Can I see some irrigation? So let me see, do I want a bone clamp here? Not bad. Okay, I know I can get it tighter with the reduction forceps but it will interfere with all the rest of the plating. It's generally in the angle area. It's very hard to place a reduction forceps. It's actually not bad the way it's right now. Teeth touching, posteriorly. What I might do is just go ahead and put a two-tiered plate on. I saved this plate that you took out. Thank you, Kelly. Okay. You are awesome. Let me see if this is the right type of plate, for our purpose here. The nice thing about it is once it's engaged, then they all go in. I think I might remove this one. Yeah, I might remove that one. The very front two holes. Okay, can I get a plate cutter, please? Plate cutter. Thank you. So I'm gonna just take this one off because I think it's too long. You see this plate that he used? Okay, I just wanna make sure you got the numbers. Thank you sir. These plates are nice, but in the angle, there's a tendency for the posterior and the anterior one to fall off the bone. I'm sorry. Do you need the trocar? I might use a trocar. I'm gonna start without it and then I'll most likely have to. I'm thinking something like this. This one might be really close to that nerve. Where is that nerve? Right there. Yeah, this has to be come out 'cause the nerve is lower. Can I get this? Yeah. Alright. Okay so that might be what we need. There we go, that looks pretty good. Okay. Okay, so I'm gonna start with superior border plates. Get this secured where you want it to. Let me see number nine. Suction right here. That's not bad. Good. I want this one to catch the middle piece. Okay, and then the nerve is right here. So, I don't know exactly which way the nerve is traveling, but I'm gonna assume the nerve is deep to this location. Just like before, we'll use a... Do you have a four-millimeter screws for when I start? But I can use a rainbow drill for all of these. So I'm gonna start by securing the top plates or top screw placement. Okay, I think - get the suction, irrigation. I gotta watch the lip here 'cause nothing's protecting it. Don't move this, don't drop. Don't worry about the suction. Just irrigate. I don't know if you're... You have a four? Yep, got a four ready. Four, please. The 2.0 locking 4. Great. Let's get this started. I'm gonna check for our screw placement and everything. This next hole is super critical. Making sure all the teeth are touching superiorly along the occlusion plane. Right there is good. Number nine, please. Position it so that one, it'll catch this middle piece, but two also wanna make sure it doesn't fall off the bone posteriorly. Again, when you're putting these screws on, these type of screws on for this plate, just go to the easiest one to get it secured where you want it and then, okay that's enough. Suction. Okay, the fourth. So once you're secure, is now secure, with these two screws, things are much more manageable. But these two screws are the key component of this reduction and fixation. The teeth look good. So I lock on this one. Okay, good. Okay. So that looks pretty good. One that's a little bit iffy. You stay right there. Can I see a...? Okay, drill. Watch the lip. Yep. That's good. Can I get eight on this one? Yep, suction. Immediately inferior to the middle piece that's essentially making into a three piece type of fracture here. Yeah, it's outer cortex only, but it'd be nice to catch that one as well. Using locking screws here again, securing this in place. Okay, suction. I might switch over to a trocar, next, but for these back ones - irrigation. Irrigate, irrigate, irrigate. This back one, this back one, I can't really get a good angle on that. These upper one's probably not a big problem but this one needs a transbuccal trocar. I'll need the transbuccal trocar, Kevin. It's right here. Oh, you guys are awesome. Look at you guys. Ready for you. You guys are a step ahead of me. So, we're gonna use this to secure this in place. Generally you want this pointing up towards you. You don't want it like this 'cause this is what allows you to see the screws and drills coming in and out. It's gonna go through the cheek to do that through a small opening. And then let me see this part. So this part, the mistake a lot of people make is, instead of just hovering right where the viewing angle window is, people tendency to do this. In that case you will end up with a situation where, number nine, please. Number nine for a second. You have a lot of - this is all wasted space that you're not gonna be able to use and it will interfere with manipulability. So we are gonna just hub it once it's in like this we'll just hub it like so, this way, like so, so that this way you're only wasting that amount of space. So when you're in a space tight like that, that makes a huge difference. And also the other mistake people make is putting it like this but now you're completely blocking your view, so it's suppose to be this way. Okay, it's a little bit loose. Can I get an empty screwdriver? It's a little bit loose, so we'll tighten that first. There we go. It's better, better, better. I do worry about the cheek. So we'll do all that under the transbuccal system trocar. Here, I'm guesstimating. These are the ones you want to use this system for. I'll go about halfway in line with this. So I'm gonna point to my tonsil, tip right to the middle of that. To here. Okay, turn the head please. You have a 15 blade? Actually, let me get a marking pen first. In this case, what we're trying to avoid, patient's mandible here, like so. Patient's gonna have marginal mandibular nerve that comes out way back here from the parotid. They'll usually come at least two finger breadths is sort of the general statement, or general assumption that we have. So, but it could be, you know, buccal branch could be kind of coming like this, so it could be anywhere in this area. So we wanna, we're doing it so that we can protect this nerve and I think where it is should be well away. So this is kind of the area that I'm pointing to, confirming my positioning in here. Yeah, that looks pretty good. A little - okay. 15 Blade. Make a little skin incision. I need about two- to three-millimeter skin incision just going through skin here. Let me get a mosquito next, please. And then I go in with this. And this is a blunt tip instrument. It's not gonna cut the nerve. Gently spread. And then pop into the mouth. So there's your instrument. Okay. So the next step is this. We'll have that pointing up towards us. Go through with this. Find the same tunnel that we created. Okay, now can I see that? Yep, perfect. Now I'll place this, again just past the viewing window. You don't want to choke up like that 'cause then now I can't move this at all. So you want to just hub it, hub that viewing window. And then this screw needs to be super duper tight 'cause if it comes apart you gotta do all this over again. So really crank on this, make sure it's super tight. And then now this piece comes out and now I'm able to move it around where I need to. Now I wanna, this handle helps me get leverage on this to move it to where I want this to go. So I'm gonna swing this around. In this case his shoulder is in the place. Okay, so that's sort of what we got going on. At the first part of this, I'm going to secure the middle segment. This one is a little bit unreliable in terms of where it's sitting. I want to secure it while it's still in place. Irrigate. Okay, can I get an eight? Eight is here. Huh? You guys are flying. I mean the tooth part was the hardest part. So, once that's been sorted out. Okay. Drill back, please. Can I see a Bovie? We have enough mucosa to close everything so not too worried about that. Can you wipe the suction, please? Thank you. That's good. So then I'm gonna, it's gonna be really hard to get this lined up like that. So I'd rather pull it away and get it in line like this so that my drill bit is in the direction I want it to go. Let me see - do you have a five? Okay, I'll get a five. And part of it's, I don't know exactly where the nerve is traveling so I'm gonna use monocortical for these, even the inferior ones. We'll use locking screws for all these and I'm keeping this steady, so that I don't have to move the direction that I'm holding this so that the screw lines up, right when it's ready to turn to the plate. Okay, the rest of these are pretty piece of cake. Okay, monocorticol on these. Right by the teeth and the nerve. Okay, let me get a four. That's a four there. Good, thank you. Let's see this one. Okay, one more four, again this screw might be in line with the nerve, so you wanna minimize going too deep on these. Confirm four locking. Thank you. Another screw going in, monocortical that's locking. Okay, we'll turn the head over a little bit more here. Okay, back. I think I can throw this on here? Like so, hm mm. Little suction. Now this one is bicortical. Can I get the eight that you had earlier? That's good. This one I feel pretty comfortable putting in bicortical just 'cause it seems well away from the tooth roots and the nerve where they would be traveling. Yes, sometimes the magnet will make it move. Yeah, it was when it hit that instrument. Okay. Now we go bicortical here. The nerve is very close to this particular location. A second. Hold that like so. Looks like I kind of come in at a little bit of an angle, get as perpendicular as I can. Do you have a four? I do. Lovely. I do. That's good. Okay. And then, now do you have a heavy needle driver? I'm noticing that this plate is lifting off the bone a little bit. Which in theory doesn't matter if you're using a locking screws, I wanna just bend it down with the needle driver because these are mini plates that will bend like that. So that will adapt it better to the plate. Better to have like essentially no gap between the bone and the plate itself. Let me get another four, please. Four millimeter. Five's good. There we go, this is our last screw. Okay. Let me just see one more thing. Number nine, please. Do you have a three? Three millimeters? What's the shortest one do you have? We have a four bone... Okay. Let me - I'll take a four, yeah that's fine. This is a slightly larger diameter, 2.3-millimeter diameter screws. So if the first screw stripped, then you could always use larger diameter screws, 'cause now the bone hole has been widened by the screw. That looks really good. Happy with all that. Good bone alignment. The teeth looks okay. Okay, let me see the empty screwdriver. We will disengage. Take this out, take this out. Thank you. Thank you so much. Let me just take a look one more time at this fracture, it was a little bit of a harder than usual because, I got this one, I got this one. Because it broke with the odd triangular piece at the bottom but that looked like it came together pretty nicely. That looks pretty good. Okay. So in this case, we use a transbuccal trocar. I almost always use it for subcondylar and the angle but in this case 'cause it's so posterior, for these sets of screws in the back, we have to use the transbuccal trocar system.

CHAPTER 7

So now, we are gonna release her out of the MMF and I'll generally prefer not to do rigid MMF just 'cause there's a lot of compliancy issues with the patients cutting them out. And also there's always concern of, with any concern for vomiting and airway concerns, best to not leave the patient in rigid MMF. Can I get a wire cutter? Yes, sir. And let me get a like clamp to get these out. So we'll cut her out of the wires. That's good. Yeah, just don't lose the wires. Get more please, there's sharp wires there. Thank you very much. More sharps, coming back to ya. Appreciate it. You want to make sure you don't lose these. These can become airway foreign bodies. Pull that straight, okay. Now can I get empty screwdriver? Okay. So in this case, we use the Stryker system for the plating. Other manufacturer may have similar type of ways to perform MFF and plates. And it's always nice to have a hardware rep that's very knowledgeable who can help us with this case going very smoothly. Okay we'll get these out and you have to get these posterior, we'll just get the retractors out, grab the screw with my instrument. And for an incision we'll need a 3-0 Victryl pops, also need a 5-0 fast. Thank you. Okay get this out, okay awesome. Okay, thank you.

CHAPTER 8

Just wanna make sure we got good occlusion after doing all that work. That looks really good. Irrigation, please. You see this area touches. This area touches here nicely too. So her occlusion has been restored. And what I mean by that is it's premorbid, we've assessed the line, we got that teeth here that was broken, try to minimize risk for infection.

CHAPTER 9

So now the next challenge we have is closing. This has to be watertight. Because if it doesn't, she'll get an infection. See there's actually a mucosal laceration. Let's get some irrigation. You have a paint stick? Can I get some iodine paint? Either the stick or just off the kit is fine. I'm just gonna irrigate with the iodine paint. This one looks good too. The first party is closing this in a watertight fashion. And you always wanna start closing at the hardest one, which normally it would be this section but in this case this is gonna be, one of the more challenging areas to close. From the - go ahead and do that. Okay. Oh yeah, let's do this. Thanks for reminding me. There's that. Thank you. Do one more. I do this to minimize risk of infection. This should be good. Thank you, irrigation, please. Get all this out. Let me see a sweetheart, please. Then I'll take a Gerald or some sort of two pickups. Yeah, can you hold it like this. Tooth Gerald. Lovely. Can I get a 3 Vicryl pops? Did you want this sent, this bone? Nah, just garbage it. We can throw that out. Okay, awesome. Thank you. 3-0 Pop. Thank you. Do you have like a longer needle driver? Yeah, I'll get that on there for ya. The next one will be on the longer. Great, awesome. Gonna close this back portion. Let me close this right here. Needle down. Okay you can leave these on to cut at the end. Can I get suture scissors? Just leave it, we'll just cut 'em all at the end. More please? Is that driver okay, or do you want... Yeah, this is perfect, thank you. We want to make sure this tooth socket, this lacerated mucosa, is closed in a watertight fashion. More please. So, we do have enough mucosa, just they're all lacerated, but these instances where you don't have mucosa, you need to cover up the, definitely the bone, especially the hardware, 'cause if you do not, it will definitely get infected. In this case, right here, I'm gonna go around this tooth. This kind of helps me make the mucosa a little bit more reliable by catching more tissue just coming across like so. All right, you have a scissors? Let's cut that. Go ahead and cut it. Yep. Just relax on this suture, and come up. Okay, relax on that, yep. Alright so then this part, so for... I don't usually do deep sutures, I know there's a lot of authors talk about that but I generally would just do, sutures along the edges, meaning not try to re-suspend everything back up. Dr. Lee, thank you for a nice case. Oh, thank you, Kelly. Yeah you're awesome, you did a great job. Thank you so much. But in this case I will suspend it, suspend some of these deeper structures. More. Okay now, just relax on that, yeah that's better. There's your nerve. Let's continue... So preserved. Actually don't want to catch the nerve with the suture by accident. And this patient did have paresthesia, numbness involving the, more of the right of the midline chin area. likely from the inferior alveolar nerve being irritated from this fracture. So I do warn them they'll most likely have worse numbness if anything. But I would expect a lot of that to resolve with time. Let them know that it might not come back a hundred percent. Especially if they have preexisting numbness. Going across that trifurcation. And angle it, with a wide tissue-spanning so that we can catch more tissue in case they fall apart. And I do stress the importance of for this patient to stay non-chewing diet for about six weeks, has to be strictly soft diet for six weeks. Thank you Kelly. Bye. Appreciate it. Okay, sweetheart back, please. I got it. Alright so we're gonna close this back one and this is usually the ones that start first just because generally most posterior is more difficult. Now that I see a mucosal tear all the way in the back, Just get that closed. I see that the gingiva is pulling away from the tooth and we'll resuspend everything. Sutures. I'll start right here, right by the tooth. Yep. Relax. Right there, suction. Can I see the P/D tonsil, Yankauer, the small. This is a hard throw, just the angle of it. Alright suction. P/D tonsil. Hold this like so. You don't have it? Don't worry about it if you don't have it, get used to operating with what you have and keep moving. So I prefer Frazier suction when we're right on the bone. If we're near soft tissue that can suck into the suction tip, then I prefer to use pediatric Yankauer, metal. Stop, move, there is the needle. Okay, good. That's a pretty good bite there. Okay, suction, or scissors. Yep, yep. These scissors? Like a little bent for this, like so. Okay more sutures. Going very posterior. Again the more posterior you go, the more difficult. In this case, I do worry about it coming apart so I'm gonna go around the tooth most likely helps me minimize the risk of it falling apart. For this suture, I'm gonna be going through the teeth here. And then come back and then go under the mucosa again. Come out submucosally and then come back submucosally out here, and then tie this to the previous suture that we started on. We'll tie this to this and then this will really prevent that mucosa from pulling apart. Especially when it's pulled apart like this from the initial accident. It's nice to have strong suture to secure on the tooth, hold the mucosa from falling apart. You have different scissors, that cuts? Alright, thanks. Okay, I'm just gonna put one more suture back here. Section out in the back. Yeah, that's good. And can we get an NG tube from you guys? Yep. Awesome. Scissors. Okay, more sutures for in the back. This necessitates going in this direction. Needle. Okay, this mucosa looks a little bit unreliable. I'm gonna loop around the tooth. Come back through. Might even come back, actually let's go up here. Put that under. I got some mucosa again. And this SH needle is working okay, but if you have a very tight corner, you can use a UR-6 needle, which has a tighter curve and is more rigid. So that's the preferred option to use in a very tight spot. Usually comes with like a 2-0 Vicryl. Okay. Okay that's good and tight. More please. I'm gonna put one right there. This one's gonna connect the mucosal laceration securely, with the tissue that looks a bit unreliable. Okay. I think that's it, let me just make sure there's nothing. Yep, suction here. Go back in. Make sure all this area gets secured properly. Now that - so that looks good. Okay. I think it's perfect. Do you have Dermabond, please. So I like to help it seal up. We are gonna apply the dermabond. I know it's usually used externally, but I typically will also use it intraorally and I do think it helps it minimize the risk of wound dehiscence, and actually will provide a watertight seal. It just peels off about a week out so just let the patient know that you are gonna have a plastic-like thing. You have one more of these? They just peel off about a week out. I like to use it intraorally to help it seal. This provides one added layer of mucosal dehiscence protection. Let it dry and then, do you have a 5-0 fast, please? Close this area, we did a transbuccal trocar. Usually one or two sutures is all you need. Okay, we are gonna check for lip movement after this when she wakes up. Can I get one more Dermabond?

While we wait, we are going to, very important, suction out her stomach, 'cause if she vomits, then it could always be an airway concern, but I just - whatever blood she swallowed can be very irritating. Okay, suction. And she did vomit this morning from blood. This - what's up. This must be a new NG tube. Okay. Okay to come up on O2, doc? Oh yeah, one second. Let me just go down one more time. Okay, let me go through her mouth quickly. Disconnect the suction. Yeah. Okay, go ahead. Oh yeah. Suck while coming back up. Just leave it connected. We have that Dermabond whenever you're ready. Great, I'll take it in a second. Okay, good. So teeth looks fine. Everything is closed. And then Dermabond right here where we put this skin suture.

CHAPTER 10

Now that we have discussed the case, I'd like to also review postoperative scans. So here's your CT axial scan. Here is the parasymphysis site, showing good restoration and atomic relationship. Here's your monocortical screws, and here's your inferior bicortical screws. Now one thing that I'm not entirely sure about, is I do think there may be persistent canine tooth left on this opposite side. So for that reason, we'll have patient be seen by oral maxillofacial surgeons once the bone's fully fused for at least six to eight weeks. This may require formal extraction once the bone has fully fused. For the body site, it shows really good reduction. Here you can see the plate and screw placement with good alignment along the outer cortex and good alignment along the inner cortex. Next, we'll also review 3D reconstruction of this case. Here is your body site, and here is your parasymphysis that's been repaired. So that concludes our discussion. Thank you.