Reconstruction of a Mandible ARTICLE by LINDA O'connor, CST

Reconstruction of a Mandible ARTICLE BY LINDA O'CONNOR, CST

serious defect of the mandible that necessitates reconstruction may occur from a congenital abnormality, osteomyelitis, osteoradionecrosis, trauma, or 1, To dura resection of a tumor. In such instances, reconstruction of the mandible is necessary because without a continuous mandible, the soft tissue of the lower face loses its supportive framework, resulting in nutritional and speech diffi- culties, oral incontinence, and cosmetic distortion. Mastication of food-necessary to maintain a normal dietdepends on an intact mandible to provide a firm foun- dation for teeth (whether natural, dental implants, or dentures) to withstand the pressure involved in chewing. Since speech occurs through the coordination of the larynx, mouth, lips, chest, and abdominal muscles, dysfunction of the mouth and lips impacts communication. Additionally, oral incontinence presents the diffihlty of maintaining tissue integrity and therefore necessitates constant attention to the mouth. Finally, cosmetic distortion may have a negative impact on a person's self-image that will impair social interaction and result in extreme emotional stress.* The case Figure 1. Trigeminal Nerve study presented in this feature follows one patient's perioperative experience with a recurring tumor of the mandible ends. Each ram& has a condyle, which ed on the internal aspect of each ramus, and the impressive reconstruction that constitutes part of the temporomandibular near its center; a mental foramen is locat- returned both form and function, there- joint ITMJ), and a coronoid process, where ed on the external aspect of the body, on by allowing the patient to resume a nor- the temporalis muscle inserts. The mas- either side of the symphysis. mal life. seter and medial pterygoid muscles insert Chewing involves mandibular move- on the ramus and angle of the mandible. ments in vertical, anteroposterior, and Anatomy and Physiology The mylohyoid muscle that forms the horizontal planes and requires coordina- Embryologically, the mandible is the floor of the mouth arises along a line on tion of the four muscles of mastication first part of the face to form: It develops the internal aspect of the mandible. The (temporalis, masseter, medial pterygoid, and in two halves that fuse along a midline anterior digastric, geniohyoid, and lateral pteygoid). The suprahyoid mus- symphysis, the fusion usually not being genioglossus muscles attach to the inter- cles (digastric, mylohyoid, geniohyoid, and, completed until the second year of life. nal aspect of the mandible near the sym- indirectly, stylohyoid) also act on the The mandible is composed of a horse- physis. The superior constrictor muscle of mandible while the infrahyoid or shoe-shaped horizontal body with two the pharynx attaches near the mandibu- "strap" muscles (sternothyroid, thyrohy- upward-angled projections frami) at its lar angle. A mandibularfbramen is locat- oid, sternohyoid, and omohyoid) stabilize

THE SURGICAL TECHNOLOGIST

-~~ the hyoid bone. The bnccitmtor and orbic- rilaris oris muscles help keep food between the occlusive surfaces of the teeth. Swallowing requires coordinated movements of the tongue, alate, hyoid bone, and muscles of the pR aryngeal wall. Most of the innervation of the mandibular area is provided by cranial nerve V, the trigeminal nerve, via its third division, the mandibular nerve (V9.The sensory component of the mandibular nerve has three branches in the area of the oral cavity: (1) the buccal nerve supplying sensation from the skin of the cheek, the buccal mucosa, and part of the gingiva; (2) the lingual nerve supplying general sensation from the mucous membrane of the anterior two-thirds of the tongue, part of the gingiva, and the mucosa of the floor of the mouth; and (3)the inferior alveolar nerve that enters the mandibular foramen to pass in a canal deep within the bone, giving off dental branches to the lower teeth and supplying the mental nerve that emerges from the mental foramen to supply sensation from the skh of the chin and, as the inferior labial nerve, the skin and mucosa of the lower lip (Figure 1). 3gure 2. Motor innervation to the four muscles of mastication. The motor component of the I mandibular nerve innervates the four muscles of mastication: the temporalis, epiglottis. One of the terminal branches pressure and constant chewing motion masseter, medial pterygoid, and lateral of the external carotid, the maxillary of the reconstructed jaw. The thinness of pterygoid muscles. Motor branches of V3 artery, provides branches to the muscles the oral cavity's mucosal lining was a also innervate the tensor tympani and of mastication and gives off the buccal factor in the high extrusion rates and tensor veli palatini muscles, as well as artery and the inferior alveolar artery. The increased inadence of infection associat- two muscles of the floor of the mouth, inferior alveolar artery and its three ed with the use of these alternative the mylohoid and the anterior belly of branches (lingual, mylohyoid, and mental) materials1 Titanium and stainless steel digastric (Figures 1 and 2). Most of the follow paths similar to those of the cor- reconstruction plates have proven more muscles of the palate, pharynx, and lar- responding nerves2 From veins that adaptable; however, they present long- ynx are innervated by branches of the accompany these arteries, venous term problems, such as metal fatigue ninth and tenth cranial nerves (glos- drainage flows into the subclavian vein and screws that eventually loosen. In sopharyngeal and vagus). The extrinsic via the anterior jugular and external jugu- addition, when dentures are placed over and intrinsic tongue muscles are inner- lar veins and into the internal jugular a bridge consisting of a plate, chewing vated by cranial nerve XI1 (hypoglossal). vein. may cause extrusion and accompanying The suprahyoid muscles are innervated infection. Vascularized bone grafts may by branches of cranial nerves VII vacial) Types of Mandibular Reconstruction be necessary when a sigruficant deficit or V3 (mandibular division of trigemi- Several methods of mandibular recon- of soft tissue exists. Autologous or allo- nal), while the infrahyoid muscles are struction exist, and each is applicable to geneic grafts, consisting of cancellous innervated by the ansa cemicalis of the specific situations. Using an extemal bone from the illac crest, calvaria, or rib, cervical plexus. approach to avoid contamination from can be considered as options that work The external carotid artery gives rise to the oral cavity-subsequent to any exci- well when the soft-tissue bed is well the facial artery, which along its course sion and/or debridement of the vascularized. gives off the submental, inferior labial, mandible--synthetic materials have Material consisting of a combination and superior labial arteries, nourishing been used as a mandibular substitute of autologous and allogeneic bone can the submental and lip regions, respec- for many years. These materials include be used as an alternative graft. In March tively. The lingual artery, also coming off single or double Kirchner wires, acrylic of 1996, Dr Melugin, Assistant Professor the extemal carotid, supplies arterial or silicone prostheses, and stainless steel of Oral and Maxillofacial Surgery at the branches to the floor of the mouth, bars, which have not proven satisfactory Medical College of Wisconsin, explained tongue, soft palate, tonsillar region, and because of their poor response to the that this combination of bone is used in

OCTOBER 1996 the "matrix band techniqueu- a proce- or thirties. It appears to occur mostly in mental and inferior alveolar nerves M dure attributed to Robert E. Marx, DDS. the mandible and may be associated dissected and protected. A SynthesTM This procedure, which has been per- with missing or buried teeth. The lesion, 2.7-mmreconstruction plate was adal formed for several years, uses allogeneic which expands the bone, may destroy ed in the following manner: three hol rib to provide a scaffolding for autolo- the cortex and/or teeth. Because the on the right and left sides of the gous bone from the posterior iliac crest. tumor grows slowly, the patient may or mandible were placed using a However, it must be processed through may not experience pain. On Panorex ZimmerTMwire driver with a .062 a bone mill before it is used. The rib also film, the lesion may appear mottled or K-wire while the plate was held in contributes bone morphogeneic protein honeycombed. Treatment requires surgi- place. The plate was then set aside. TI (BMP), which induces the osteoplastic cal excision or resection of the tumor bony cuts were marked using a bur, a cells of the periosteum to produce bone. which, although benign, can be difficult the resection was completed with a The cancellous bone from the posterior to remove because of the gelatinous Zimmer reciprocating saw. The osteot iliac crest contains the highest concen- nature of the bone affected by the my extended from the extraction site ( tration of osteoplastic (bone forming) tumor. Prognosis is good; however, tooth No. 29 to the anterior border of cells of all the possible graft donor sites. recurrence is unpredictable.3 the mental foramen and through the Eventually, the rib scaffold is replaced inferior border of the mandible. Using by the patient's own bone. By combin- Tumor Resection flexible ruler on the left side of the ing autologous and allogeneic bone, Approximately 6 weeks after the initial mandible, the osteotomy was measure minimal bone resorption occurs; thus, visit, following which the diagnosis was 12 mm medial to tooth No. 30 and sufficient bony height is achieved. The made, the patient was brought to the directed anterior and inferior to the newer dental implants, osseointegrated surgical suite for tumor resection. Under mental foramen through the inferior artificial teeth, can provide patients with general anesthesia, the patient was border of the mandible. The resected a more normal oral cavity. They can be prepped and draped following the portion was removed and placed on a implanted once the natural process of specifics outlined on the surgeon's pref- separate table to be radiographed. The bone remodeling in the reconstructed erence card. intraoperative radiographs indicated t mandible occurs. A throat pack was placed in the neoplasm had been removed entirely. , Mandible reconstruction requires oral patient's oropharynx, and an Erich arch a precaution, an additional 2 mm to 3 surgeons to call upon both their knowl- bar was shaped and applied to the max- mm of bony margin was excised. The edge and artistry. It also provides an illa. For the mandible, a combination of patient was placed in intermaxillary fi: opportunity for surgical technologists to Dingman wires and Ivy loops, fashioned ation. After thorough irrigation, the prc display specialized skills as part of the from stainless steel wire, were placed formed reconstruction plate was securc surgical team. The following case study for later intermaxillary fixation. tightly to the mandible using 2.4-mm examines one patient's perioperative Lidocaine with epinephrine was injected bone screws of appropriate lengths. experience resulting from the treatment for local hemostasis near the inferior Intermaxillary fixation was released of a recurring tumor of the mandible. border of the mandible and a transcuta- and intraoral closure of the mucosa wa The reconst&tion performed by the neous incision was marked with a surgi- accomplished using 2-0 polyester surgical team and perioperative support cal marking pen. The incision was made (EthibondTM)suture to secure the mus- staff restored normal form and function once the effects of the lidocaine were culature of the tongue base to the recor to the oral cavity, thus significantly observed. Both sharp and blunt dissec- struction plate. Following this, the men improving the patient's quality of life. tion techniques were performed, and a talis muscle was reapproximated and nerve stimulator and electrocautery 3-0 polyglactin 910 (VicrylTM)suture w: Patient History were used when necessary. When the used for the final closure of the mucosa A 39-year-old female presented with dissection was completed, the area was Extraorally, closure was achieved by pain at the site of a previous surgery. packed with saline-moistened sponges. attaching the digastric muscles to the The pain occurred when her partial den- Before intraoral incision and dissec- plate using 2-0 and 3-0 polyester ture was inserted and when the area tion, lidocaine with epinephrine was (Ethibond) sutures. This was followed was touched. A PanorexTMfilm showed injected again for local hemostasis. An by a multiple-layer closure using 3-0 radiolucent areas at the symphysis, and incision was made around the teeth and and 4-0 polyglactin 910 (Vicryl) and 5-0 the occlusion showed border irregulari- extended in the labial aspect of the sym- nylon (EthilonTM)sutures and the place ty. Because the patient was in good physis region to allow for excision of a ment of a 2-0 silk (Perma-handTM) health otherwise, this appeared to be a cuff of tissue surrounding the lesion. suture that secured a Jackson-Pratt recurrence of a tumor that previously The incision continued around the teeth drain. The oropharynx was then suc- had received nonresection treatment, in the lower left quadrant. Dissection tioned dry, the throat pack removed, rather than a newly occurring (primary) was performed using sharp and blunt and intermaxillary fixation was reestab- neoplasm. A treatment plan was based techniques (when possible intraorally), lished. on an incisional biopsy and a computed and then was completed via the transcu- tomography (CT) scan. A mandibular taneous incision after removal of the Postoperative Period odontogenic myxoma was diagnosed. sponges. On the sixth postoperative day, the Odontogenic myxoma is a tumor that Tooth No. 29 was extracted, a portion patient returned to the clinic because originates from the tooth germ in the of the inferior alveolar nerve on the she experienced drainage from the inci- jaw, usually during a person's twenties right side was decorticated, and the sion site. The wound was incised and drained, and the patient was placed on (Table 1).Since part one of the proce- ined by the oral surgery residents. Tl antibiotics and admitted to the hospital. dure involved harvesting bone from the circulator was directed to perform th After 3 days, the patient was stable and posterior iliac crest, suitable instrumen- surgical prep according to the surgeo thus, discharged. tation was arranged on the Mayo stand, preference card. This consisted of a ti Drapes, cautery, suction, and instrument ture of iodine scrub followed by a tin Surgical Preparation for Mandibular mat were also arranged in order of use ture of iodine paint. Reconstruction and placed on the Mayo stand to facili- Three factors-multiple patient posi- tate the process. Harvesting the Bone tions, several instrument trays, and spe- After completing the prep, the surgic, cialty equipment used for this type of Part I - Bone Harvesting site was draped by squaring off with mandible reconstruction-necessitated four towels, which were secured with appropriate room preparation in the Anesthesia Induction four towel clips. A disposable laparotc surgical suite. The senior resident The patient was brought into the operat- my drape was placed and secured wii informed the circulator and the surgical ing suite on the gurney, which was posi- the adhesive strips built into the drap technologist that the patient would be tioned dose to the anesthesia equipment The elemcautery and suction tubing induced in the su ine position, turned (the OR table / bed having been previ- were secured to the drape, and the prone to harvest 5,e posterior iliac crest ously moved closer to the sterile area to appropriate ends were passed to the c graft, and returned to the supine posi- allow the necessary space). During the culator for connetion to their respecti tion for the remainder of the procedure. induction adpre aration for patient' units. With the placement of the light It was decided to induce the patient positioning, both 5.e circulator and sur- handles and the instrument mat, drap while supine on the ambulatory surgery gical technologist maintained a vigil to ing was complete. Subsequent to chec cart. The operating room table and one ensure the sterile field was not ing with anesthesia personnel, the sw arm board were padded with egg-crrate breached. The general anesthetic was gem made a standard curvilinear inci type material (2 inches thick) and cov- begun with sedatives and a numbing of sion over the posterior iliac crest. Shar ered with linen sheets. Chest rolls of the nasopharynx before dilatation and dissection exposed the posterior iliac appropriate size were obtained and insertion of a nasal endotracheal (ET) crest, and electrocautery was used jud. positioned on the OR table, and a draw tube. Placement of this tube was accom- ciously. When the lateral aspect of the sheet was draped over them. Other nec- plished with the assistance of an anes- crest was exposed and the periosteum essary furniture and supplies included a thesia technician and staff anesthesiolo- elevated, a block consisting of both COI &foot-long back table, bipolar cautery gist using a fiberoptic bronchoscope. tical and cancellous bone was removec and wall adapter, and air cord for the Once the ET tube was in place, it was using various osteotomes. An assort- air-powered equipment (Zimmer Power secured with tape, and the patient's eyes ment of gouges and curettes was used SystemTM). were protected. A towel was wrapped to harvest approximately 65 ccs of resic A case cart system obtained from cen- around the head turban-style to cover ual cancellous bone and some other tral sterile supply was brought into the the patient's hair and was secured with small fragments of cortical bone. All of OR suite. It contained the sterile sup adhesive tape. this bone was placed in a specimen cor plies and instrumentation outlined on tainer and moved to the back table for the staff surgeon's computerized prefer- Patient Positioning and Preparation safekeeping. ence card. Specialty supplies included a The OR bed was positioned next to the The wound was irrigated with copi- plating system (Synthes Mandible gurney, and both were locked in place. ous amounts of antibiotic irrigating Trauma SystemfM), a bone bank rib The patient was rolled onto her side and solution and packed with a hemostatic (MusculoskeletalTransplant then lifted onto chest rolls (previously agent (AviteneTM);when hemostasis wa FoundationfM), and various pharmaceu- positioned on the OR bed) by available achieved, a dosed-wound drain 04 Fr ticals: 1% lidocaine with epinephrine OR team members. The gurne was Jackson-Pratt)was placed through a (1:100,000) and a bone reconstitution unlocked and removed from tie room separate puncture made anterior to the solution that the OR pharmacy prepares after all monitoring and lV lines were incision and bony defect. The area was specially. The solution, which is pre- ascertained to be dear of its path. The then closed in layers using polyglactin pared in a pour bottle, consists of 50,000 p patient's position was adjusted on the 910 wcryl) suture in appropriates sizes bacitracin (U 'ohn) and 500,000 p OR bed to ensure proper positioning of Staples were used to approximate the polymixin (PL acia) in 100 ml of nor- the chest rolls. The head and neck were skin edges. The drain was secured with mal saline with a 7-day expiration. supported by two stacked, doughnut- a silk (Perma-hand) suture. A small Based on the information received con- shaped pads, and the elbows and wrists piece of nonadherent dressing and ster- cerning patient positioning, extra drap- were padded and the arms secured. The ile 4x4 dressing sponges were applied tc ing materials and surgical gowns were knees were already cushioned by the the incision site, and a drain sponge wa: obtained and held aside to open at the egg-aate pad on the OR bed, and two placed around the drain. The drapes appropriate time. pillows were placed under the lower were removed and the dressings were Instrumentation was set up on the calves to suspend the feet. secured with tape. back table, and the instruments used The circulator placed the electrosurgi- most often were placed on the Mayo cal grounding pad on the lateral aspect stand; other instruments would be of the thigh on the side opposite the brought to the Mayo stand as needed graft site. The operative site was exam-

OCTOBER 1996 Part I1 - Mandibular Reconstruction Table 1. Instruments Required for the Surgical Procedure Patient Repositioning and Preparation Back table setup The gurney was returned to the OR suite and locked into position alongside Instrument Trays the OR bed. The patient was rolled off Oral general - soft tissue instruments Synthes 2.4 Mandible Trauma SetTM the chest roll on the gurney side, and and periosteal elevators Tessier Bone MillTM the chest roll was removed. The patient Oral saggital - mandibular Basic 1 - basic soft-tissue instruments was then rolled off the OR bed onto the osteotomy instruments LambottTMosteotomes gurney by the OR team. Anesthesia per- Zimmer Power SystemTM Tessier Bone BenderTM sonnel checked the patency of patient- ObwegeserTMretractors airway and IV tubing while the circulator removed the remaining chest roll Mayo setup - Part 1 from the OR bed. This time, the patient #3 knife handles: 1 #10 and #15 7-inch MetzenbaumTMscissors was lifted onto the OR bed in the supine blade on each 5-inch tissue forceps with teeth position. The gurney was unlocked and 8-inch DebakeyTMtissue forceps 6-inch curved Crile hemostats removed from the room once all moni- 6-inch KocherTMclamps Bunion elevator toring and IV lines were determined to Freer elevator be clear of its path. The patient was adjusted on the OR bed to ensure prop- Placed on Mayo as needed: er positioning: the head resting on a Rake retractors Gelpi retractors doughnut-shaped pad, the left arm Selection of osteotomes Mallet extended on a padded arm board for Bone gouges Bone curettes anesthesia access, the right arm secured S ecimen cup to collect bone graft Needle holders alongside the patient's body, and a pil- sRarps safe Suture scissors low placed under the knees for lumbar Various suture material: Skin staples support. 0,2-0 polyglactin 910 (VicrylTM) The grounding pad was inspected to 3-0 silk (Perma-handTM) ensure that proper contact was maintained. The ET tube was readjusted and Mayo setup - Part 2 secured to angle toward the forehead #3 knife handles: #15 blades on each 3-inch tenotomy scissors while avoiding placing tension on the AdsonTMforceps with teeth 5-inch DebakeyTMforceps nostrils. A sterile plastic drape (1010 Vi- AdsonTMforceps without teeth Mosquito hemostats: curved & straigh DrapeTM)was placed over the lower lip MoltTMperiosteal elevator FreerTMelevator, slightly curved below the vermilion border and opened FreerTMelevator with one end SeldinTMperiosteal elevator cephalad in an aseptic fashion. The strongly curved ObwegeserTMretractors - various sizes lower face, neck, and drape were washed with a soap (pHisoHexTM)and Placed on Mayo as needed: saline mixture and rinsed with saline- Disposable nerve stimulator Power handpieces and cord saturated 4x4 sponges. From Synthes 2.4 Mandible (Zimmer Power SystemTM) Trauma SetTM: Needle holders Instrument Preparation Screw drivers Suture scissors After the bone harvesting, but before Depth gauge Sharps safe removing the drapes, the cautery, suc- Drill bit guide tion tubing, and instrument mat were Bone cutter removed from the drape and placed Various suture material: onto the Mayo stand. They were then 2-0,3-0 polyglactin 910 (VicrylTM) secured and kept sterile for use in the 3-0 chromic surgical gut suture reconstructive portion of the surgery. 4-0 nylon (EthilonTM) Care was taken to maintain the sterility 3-0 silk (Perma-handTM) of the field ends while the unsterile portion was suspended off the Mayo, and tect the sterility of the light handles. The returned to their trays. Instruments the ends balanced on the base of the scrub person remained sterile to prepare needed for the reconstruction were Mayo. In an effort to prevent contami- the Mayo stand for the reconstructive arranged on the Mayo tray (Table 1). nation, sterile items were grouped portion of the surgery and to guard the together and placed on the sterile side sterile field while the unsterile team Mandible Reconstruction of the room. The Mayo was moved care- members repositioned the patient. At the completion of the prep, the surgi fully, along with the back table and ring Instruments used for the bone harvest cal site (including the Vi-Drape-covered stand bearing a rinse basin. The lights procedure, which were no longer need- mouth) was draped by squaring off were adjusted toward the ceiling to pro- ed, were rinsed in the basin and with four towels that were secured with

THE SURGICAL TECHNOLOGIST OCTOBER 1994 four towel clips. Then, a disposable reconstituted and floating in an antibiot- and good contact with the resected split-sheet dra was placed and ic bath. A Zimrner saw was set up, and mandible ends bilaterally. secured with tre adhesive strips built the air hose was attached to the back A biianual palpation (conducted into the drape. The top edges of a dis- table. It was connected to an unsterile through the Vi-Drape to prevent conta- posable half-sheet drape were secured nitrogen extension hose that ran to the mination from the oral cavity by press- to IV standards placed alongside the wall supply and was set at 110 psi. The ing the drape into the oral cavity and patient's left side to construct an anes- staff surgeon selected a saw blade that along the alveolar ridge) was executed thesia screen. The lower edges were was attached to the saw and tested by to ensure that the oral mucosa remaine secured to the split sheet by the scrub the scrub, and the rib was split length- intact with no communication between person with Kelly clamps. The electro- wise. Following this, the saw handpiece the graft and the oral cavity. The new cautery and suction tubing were secured was removed and replaced with a bun. occlusion was purposely left slightly to the drape, and the appropriate ends handpiece (Zimmer Surgairtome IP) higher to permit bone resorption. The were passed to the circulator for connec- armed with the appropriate burr guard area was irrigated thoroughly and do- tion to theu respective units. The instru- in place and a burr selected by the sur- sure completed in several layers. The ment mat was placed on the patient and geon. The two pieces of rib were hol- preexisting strap and platysma muscles the OR lights were adjusted. lowed out until thin, and the posterior were replaced over the anterior The patient was injected with 1% portion of the rib crest was rendered mandible and reconstruction plate, and lidocaine with epinephrine along the more flexible by crimping with a sutured with polyglactin 910 (Viayl) previous submental incision. A large TessierTMbone bender. Both ieces were suture of appropriate size in an inter- keloid that had formed across the old returned to the antibiotic ba s, on the rupted, horizontal mattress fashion. A incision line was excised. Sharp dissec- back table for safekeeping until needed. closed-wound drain was placed'just tion continued through the skin and Attention was tumedto hepieces of inferior to the anterior border of the subcutaneous tissues, and proceeded cortical and cancellous bone previously mandible and secured with silk (Perma. along the scar line down to the anterior harvested from the posterior iliac crest. hand) suture. Interrupted subcutaneous belly of digastric muscle, then up to the Once the bone was thoroughly shred in sutures of polyglactin 910 (Viayl) sutur anterior border of the mandible. A dis- a Tessier bone mill, it was returned to material were placed for good wound posable nerve-stimulator unit was the specimen container for safekeeping eversion, and skin was dosed with a applied to identify nerves, and electro- on the back table until needed. running stitch of nylon (Ethilon) suture. cautery was used judiciously. The At this point, the posterior piece of The oral cavity was exposed by periosteum was sharply incised at the rib was pressed against the medial removing the Vi-Drape. The adhered right and left segments of the mandible aspects of the mandibular segments edge was peeled from below the lower and carried across the inferior border of bilaterally. After being measured and lip edge, a throat pack was placed, and the mandibular reconstruction plate. cut to the appropriate length, it was the patient was placed in maxillo- With the plate exposed, the screw secured with a mandibular reconstruc- mandibular fixation using Ivy loops on lengths were assessed. The length of tion screw of appropriate length on each the left side of the mandible and a three of the screws was determined to side. Copious amounts of irrigatin Dingrnan loop on the right. After be excessive; they were therefore solution were used while drilling $ removing the throat pack and suction- replaced with screws of appropriate holes. Using a Zimrner saggital saw, the ing the oral cavity dry,the loops from length. The screws that had been anterior portion of the rib crest was both sides were secured to the preexist- removed were cleaned off in the rinse notched at each end to ensure a secure ing maxillary arch bar, which was tight- basin and saved on the back table by the fit around the screws attaching the ened and had several wires replaced scrub person. A pocket of tissue was mandible reconstruction plate. Four that had broken during previous weeks. developed in the anterior mandible, small holes were drilled into the rib A pressure dressing was applied to the thus allowing for the maintenance of the crest to pass two 25-gauge wires, which neck wound. alveolar height necessary to accommo- secured the bone graft to the anterior The patient's emergence from the date the bilateral segments. Bimanual aspect of the plate. A small, round burr general anesthetic occurred in the OR palpation of the oral cavity (pressing the was used to create six small holes in the suite. The ET tube was removed in the drape into the oral cavity) was per- posterior portion of the rib graft to Postanesthesia Care Unit. Upon recover- formed through the Vi-Drape, which allow for reapproximation of the floor- ing sufficiently, the patient was trans- was serving as a barrier to prevent con- of-mouth genioglossus and geniohyoid ported to her room on the nursing floor. tamination from the oral cavity. This musculature to this rib strut using a was conducted to verify that an ade- polyglactin 910 (Vicryl) suture in a verti- Postoperative Period quate mucosal pocket had been created cal mattress fashion. Once the muscula- The patient continued to do well. The to prevent the formation of excessive ture was reattached, the previously neck sutures were removed and scar tissue between the oral mucosa and milled cortical / cancellous bone graft replaced with Steri-stripsTMon the sixth bone graft. was packed tightly into syringes, which postoperative day. On the twelfth post- While the residents injected the sub- were used to deliver the graft material operative day, periodic injections of the mental incision line and began the dis- to the mandibular defect. This made it corticosteroid KenalogTM(10mg / ml) section, the staff surgeon (using space possible to achieve not only an excellent were begun in the keloid that had allotted at the back table) began to bony height level, but also a tightly formed in the left submandibular region shape the freeze-dried rib, which was packed placement with no dead space at the drain site and incision. The sta-

THE SURGICAL TECHNOLOGIST OCTOBER 1996 pies at the iliac graft site were removed. gical instrumentation and supplies, and Intramaxillary fixation remained stable the surgical procedure itself as well as throughout the postoperative course the associated postoperative considera- and was released 6 weeks postopera- tions. Mandible reconstruction is an tively. The patient continued to improve operation that emphasizes an oral sur- and was checked regularly. Two and geon's scope of knowledge and artistry. one-half months postoperatively, the In addition, this procedure allows surgi- graft, mucosa, and gingivae were found cal technologists to demonstrate their to be intact, and the submental incision specialized skills. and treasure;for AST keloid showed evidence of responding The case study examined one Region 5; she currently - &j. I$:.e' *.h.y to the Kenalog injections. patient's perioperative experience in represents Region 5 on the Bylaws Commtttee. She also received the PEAK Awt which a recurring tumor of the mandible for Advanced Generaltst in 1994 and the 1995 AST Conclusion and the resulting defect were treated. Outstanding Achievement in Publtc Relations Awar A serious defect of the mandible may The impressive reconstruction performed occur from a congenital abnormality, by the surgical team and perioperative osteomyelitis, osteoradionecrosis, trau- support staff made a significant differ- Other Suggested Anatomy Referenct ma, or resection of a tumor. Several ence in the patient's quality of life. A Hole JW. Human Anatomy and Physiology. 4th methods of mandible reconstruction are Dubuque, Iowa: Wm. C. Brown Publishers; possible; each is suitable for certain situ- References 1987. JE. Moore KL. Clinically Oriented Anatomy. 3rd ec ations. The surgical technologist will 1. Anderson Grant's Atlas of Anatomy. 7th ed. Baltimore, Md: Williams and Wilkins Compa find that the mandibular reconstruction Baltimore, Md: Williams and Wilkins 1992. procedure calls upon his/ her knowl- Company; 1978:&15. Moore KL. The Developing Human: Clinically 2. Ruberg RL, Smith DJ.Plastic Surgey of the Oriented Embryology. 4th ed. Philadelphia, Pa: edge of the indications for such surgery, Head and Neck. St Louis, Mo: Mosby-Year the anatomy and physiology of the W. B. Saunders Company; 1988. Book, Inc; 1994:400-401. Tortora GJ,Grabowski SR. Principles of Anator mandible, patient preparation tech- 3. Shafer WG. A Textbook of Oral Pathology. and Physiology. 7th ed. New York, NY: Harper niques, the selection of appropriate sur- Philadelphia, Pa: W. B. Saunders Company; Collins College Publishers; 1993. 1983:295-297.