• 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

#Arrangoiz #CancerSurgeon #HeadandNeckSurgeon #SurgicalOncologist #MountSinaiMedicalCenter #MSMC #Miami #Mexico

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