Mandibulotomy

A mandibulotomy can be performed in one of three locations:
- Lateral:
  - Through the body or angle of the mandible
- Midline
- Paramedian
A lateral mandibulotomy has several disadvantages:
- First, the muscular pull on the two segments of the mandible is unequal:
  - Putting the mandibulotomy site under significant stress and causing a delay in healing:
    - For this reason, intermaxillary fixation may be required
- Second, the ability to gain access to the suture line to maintain cleanliness following surgery in the oral cavity is hampered as a result of intermaxillary fixation leading to poor oral hygiene and the potential risk for sepsis of the suture line
- Third, a lateral mandibulotomy poses several anatomic disadvantages including:
  - Denervation of the teeth distal to the mandibulotomy site and the skin of the chin:
    - As a result of transection of the inferior alveolar nerve
  - A lateral mandibulotomy also causes devascularization of the distal teeth and the distal segment of the mandible:
    - From its endosteal blood supply
  - The exposure provided by a lateral mandibulotomy is limited
  - If the patient needs postoperative radiation therapy:
    - Delayed healing can lead to complications at the site of the mandibulotomy
- For these reasons, a lateral mandibulotomy:
  - Is not recommended
By placing the mandibulotomy in the anterior midline:
- All the disadvantages of a lateral mandibulotolotomy:
  - Are avoided
- However, splitting the mandible in the midline:
  - Requires extraction of one central incisor tooth:
    - To avoid exposure of the roots of both central incisor teeth:
      - Which are at risk of extrusion
    - Extraction of one central incisor tooth alters the aesthetic appearance of the lower dentition
  - In addition, a midline mandibulotomy requires:
    - Division of muscles arising from the genial tubercle, that is:
      - The geniohyoid and genioglossus:
        
        Leading to a delayed recovery of the functions of mastication and swallowing
- Therefore a median mandibulotomy:
  - Also is not preferred for these reasons
A paramedian mandibulotomy:
- On the other hand, avoids all the disadvantages of a lateral mandibulotomy and the sequelae of a midline mandibulotomy
- It offers significant advantages, such as:
  - Wide exposure
  - Preservation of the geniohyoid and genioglossus muscles:
    - Leading to preservation of the hyomandibular complex
  - The only muscle requiring division is the mylohyoid muscle:
    - Which leads to minimal swallowing difficulties
- A paramedian mandibulotomy:
  - Does not cause denervation or devascularization of the skin of the chin or the teeth and mandible
- Fixation at the mandibulotomy site is easy
- The site of the mandibulotomy is able to withstand radiation therapy if the patient needs postoperative treatment
Thus at present a paramedian mandibulotomy:
- Remains an optimal surgical approach for access to posteriorly located larger lesions of the oral cavity and tumors of the oropharynx and parapharyngeal space