DATE OF OPERATION: MM/DD/YYYY
PREOPERATIVE DIAGNOSES:
1. Maxillary hypoplasia.
2. Mandibular hyperplasia.
3. Skeletal class III jaw deformity.
POSTOPERATIVE DIAGNOSES:
Not Available.
OPERATIONS PERFORMED:
1. LeFort I total maxillary osteotomy with rigid skeletal fixation utilizing titanium bone plates and screws and onlay bone grafting with allogenic bone.
2. Bilateral mandibular ramus osteotomies with skeletal/dental intermaxillary fixation.
SURGEON: John Doe, DDS
ASSISTANT: Jane Doe, DMD
ANESTHESIA: General.
ANESTHESIOLOGIST: Bradford Doe, MD
DESCRIPTION OF OPERATION: The patient was taken to the operating area in a sedated condition and placed in a supine position on the operating table. After the successful induction of anesthesia and the placement of a nasal endotracheal tube, the patient was prepared and draped in the usual manner for an intraoral surgical procedure. Attention was directed intraorally. The oropharynx was suctioned freed of all secretions and debris. A throat pack was placed about the endotracheal tube. Xylocaine 2% with 1:100,000 epinephrine was then infiltrated in the maxillary labial areas and into the bilateral ramus areas of the mandible. Then, 0.5% Marcaine with 1:200,000 epinephrine was used to get bilateral inferior alveolar nerve blocks. After the placement of the local anesthetic, Ivy loop appliances were applied to the maxillary and mandibular molar dentition on both the right and left side.
Attention was then directed to the right ramus where, by the use of a #15 Bard-Parker blade, incision was made over the external oblique ridge, going from the mid portion of the coronoid process down to the distal of the second molar. Dissection was carried off the lateral surface of the mandible to expose the lateral surface of the mandible from the sigmoid notch superiorly, inferiorly to the facial notch and posteriorly along the posterior border of the mandible. At this time, a Bauer retractor was placed into the sigmoid notch and a Merrill retractor was placed along the posterior border of the mandible to allow for access for the osteotomy. At this time, utilizing a reciprocating saw and the Stryker handpiece, a vertical osteotomy cut was initiated just through the lateral cortex, going from the sigmoid notch superiorly down to the angle. Once the osteotomy cut had been scored, moist dressing was placed in the surgical site and attention was directed to the left ramus area, where similar dissection and similar initially osteotomy cuts were accomplished.
At this time, attention was directed to the maxilla where, by the use of a #15 Bard-Parker blade, incision was made in the greatest depths of the mucobuccal fold, going from the first molar posteriorly, anteriorly to the midline. Dissection was carried off the anterior face of the maxilla to expose the maxilla from the piriform aperture anteriorly, posteriorly to the pterygoid plates, and superiorly to just below the infraorbital nerve. Further dissection was carried to elevate the nasal mucosa from the superior portion of the maxilla and the lateral nasal wall. A small malleable retractor was then placed. A 701 fissure bur was then used to make indicating marks above the apices of the cuspid and molar teeth, and then utilizing a reciprocating saw and the Stryker handpiece, an osteotomy cut was made from the pterygoid plates posteriorly to the piriform aperture. A small osteotome was used to continue the osteotomy along the lateral nasal wall to the perpendicular plate of the palatine bone and along the lateral maxillary wall to the pterygoid plates. A gently curved osteotome was then used to separate the pterygoid plates from the distal aspect of the maxilla. Once this had been accomplished, a nasal septal osteotome was used to separate the nasal septum and vomer from the superior aspect of the maxilla.
Now, utilizing firm finger pressure, down-fracture maneuver was accomplished. The Le Fort I osteotomy was then mobilized to freely move it anteriorly. The greater palatine vessels were intact on both the right and left side. Further bone was removed from the superior portion of the maxilla to allow for free advancement. Rowe disimpaction forceps was used to freely mobilize the maxilla in all dimensions. At this time, a previously prepared acrylic intermediate splint was brought intraorally and the maxilla was brought into its anatomically determined occlusion and secured by the use of multiple 25 gauge stainless steel wires. The maxillomandibular complex was then superiorly repositioned into its appropriate anatomic relationship, having been advanced approximately 6 mm. A 1.7 mm titanium L-plate was adapted to the right and left piriform aperture and secured by the use of five 5 mm titanium bone screws of 1.7 mm diameter. In the posterior maxilla, 2-hole plates were contoured to fit across the osteotomy and these were 2 mm plates that were secured with two 2 x 5 mm titanium bone screws.
Once this had been accomplished, it was found that the maxilla had been rigidly stabilized. Prior to stabilization, the superior port of the maxilla along the nasal crest was smoothed with a rotating cutting instrument and a few millimeters of nasal septal cartilage was removed to allow for free repositioning of the maxilla and the soft tissue was closed by the use of interrupted and continuous running 4-0 Vicryl sutures. Now that the maxillary osteotomy had been well stabilized, the intermaxillary fixation was released, the intermediate splint was then removed, the oropharynx was suctioned free of all secretions and debris and the moist throat pack was removed about the endotracheal tube.
At this time, a previously prepared acrylic splint in its final jaw relationship was brought intraorally and tested on the dentition. At this time, attention was then directed to the right and left ramus areas where, by the use of an oscillating saw, a vertical osteotomy was completed, going from the greatest depth of the sigmoid notch down to the angle of the mandible. The proximal fragment was then brought laterally. Muscle attachments on the medial aspect were removed. Osteotomies were accomplished on both the right and left side. At this time, the mandible could be freely repositioned into its anatomically determined occlusion and the previously placed throat pack had been previously removed. The acrylic splint was used to reposition the mandible ideally into its anatomic location and the patient was secured into intermaxillary fixation utilizing multiple 25 gauge stainless steel wires.
Attention was then directed to the ramus area, where the inner aspect of the proximal segment was smooth with rotating cutting instruments so that the proximal segment laid passively against the distal segment. A 1.1 mm wire pass bur was used to place a transosseous wire through the lateral cortex of the distal segment through which a 26 gauge stainless steel wire was placed. This was passed around the posterior aspect of the proximal segment. The posterior segment was then gently but firmly seated into the glenoid fossa and this transosseous wire was tightened, to secure and stabilize the proximal segment to the lateral aspect of the distal segment. Once this wire had been placed and tightened, it was turned down into the bony crevice.
At this time, it appeared that both osteotomies had been positioned appropriately. At this time, a piece of iliac crest that had been procured from allogenic bone bank had been reconstituting in normal saline with a gram of Kefzol. The reconstitution was to fill any bone cavities and soften the bone for placement. An area on the anterior face of the maxilla measuring 23 x 5 x 5 mm was noted and a piece of this allogenic cadaver bone was cut into two segments that were 23 x 6 x 5 mm in height. This was shaped and contoured to fit the anterior face of the maxilla on both the right and left side. Two separate pieces were contoured. Once they had been contoured to fit, 2 mm stabilizing screws were placed, both 8 mm in length x 2 mm in diameter, to secure and stabilize the allogenic bone graft along the anterior face of the maxilla. This was accomplished on both the right and left side to 22 to 23 mm x 5 to 6 mm x 5 mm pieces of allogenic bone obtained from the allogenic cadaver iliac bone was placed on the maxilla and stabilized. The margins were re-contoured for proper facial balance.
At this time, the surgical area was irrigated with copious amounts of normal saline. A double skin hook was placed in the midline. A single skin hook was then used to grab the transverse nasalis muscle on both the right and left side, through which a 3-0 Ethibond suture was placed. This was tightened to re-anastomose the transverse nasalis muscle across the anterior part of the maxilla and floor of nose to help prevent widening of the alar base. Once this had been accomplished, a V-Y closure of the maxillary vestibular incision was accomplished utilizing interrupted and continuous running 3-0 Vicryl suturing. The V-portion was advanced toward the midline, approximately 5-10 mm and the Y-portion was closed by the use of interrupted 3-0 Vicryl suturing.
At this time, attention was directed to the ramus area on both the right and left side. The area was irrigated with copious amounts of normal saline. Medium Hemovac drains were placed bilaterally and the soft tissues closed by the use of interrupted and continuous running 3-0 chromic suture. Blood loss for the procedure was approximately 800 mL. Sponge count and needle counts were correct at the termination of the operation. The patient was administered Kefzol three times during the operation and dexamethasone 10 mg during the course of the operation. The patient tolerated the procedure well, was extubated in the operating room and transferred to the recovery area in a stable condition.
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PREOPERATIVE DIAGNOSES:
1. Maxillary hypoplasia.
2. Mandibular hyperplasia.
3. Skeletal class III jaw deformity.
POSTOPERATIVE DIAGNOSES:
Not Available.
OPERATIONS PERFORMED:
1. LeFort I total maxillary osteotomy with rigid skeletal fixation utilizing titanium bone plates and screws and onlay bone grafting with allogenic bone.
2. Bilateral mandibular ramus osteotomies with skeletal/dental intermaxillary fixation.
SURGEON: John Doe, DDS
ASSISTANT: Jane Doe, DMD
ANESTHESIA: General.
ANESTHESIOLOGIST: Bradford Doe, MD
DESCRIPTION OF OPERATION: The patient was taken to the operating area in a sedated condition and placed in a supine position on the operating table. After the successful induction of anesthesia and the placement of a nasal endotracheal tube, the patient was prepared and draped in the usual manner for an intraoral surgical procedure. Attention was directed intraorally. The oropharynx was suctioned freed of all secretions and debris. A throat pack was placed about the endotracheal tube. Xylocaine 2% with 1:100,000 epinephrine was then infiltrated in the maxillary labial areas and into the bilateral ramus areas of the mandible. Then, 0.5% Marcaine with 1:200,000 epinephrine was used to get bilateral inferior alveolar nerve blocks. After the placement of the local anesthetic, Ivy loop appliances were applied to the maxillary and mandibular molar dentition on both the right and left side.
Attention was then directed to the right ramus where, by the use of a #15 Bard-Parker blade, incision was made over the external oblique ridge, going from the mid portion of the coronoid process down to the distal of the second molar. Dissection was carried off the lateral surface of the mandible to expose the lateral surface of the mandible from the sigmoid notch superiorly, inferiorly to the facial notch and posteriorly along the posterior border of the mandible. At this time, a Bauer retractor was placed into the sigmoid notch and a Merrill retractor was placed along the posterior border of the mandible to allow for access for the osteotomy. At this time, utilizing a reciprocating saw and the Stryker handpiece, a vertical osteotomy cut was initiated just through the lateral cortex, going from the sigmoid notch superiorly down to the angle. Once the osteotomy cut had been scored, moist dressing was placed in the surgical site and attention was directed to the left ramus area, where similar dissection and similar initially osteotomy cuts were accomplished.
At this time, attention was directed to the maxilla where, by the use of a #15 Bard-Parker blade, incision was made in the greatest depths of the mucobuccal fold, going from the first molar posteriorly, anteriorly to the midline. Dissection was carried off the anterior face of the maxilla to expose the maxilla from the piriform aperture anteriorly, posteriorly to the pterygoid plates, and superiorly to just below the infraorbital nerve. Further dissection was carried to elevate the nasal mucosa from the superior portion of the maxilla and the lateral nasal wall. A small malleable retractor was then placed. A 701 fissure bur was then used to make indicating marks above the apices of the cuspid and molar teeth, and then utilizing a reciprocating saw and the Stryker handpiece, an osteotomy cut was made from the pterygoid plates posteriorly to the piriform aperture. A small osteotome was used to continue the osteotomy along the lateral nasal wall to the perpendicular plate of the palatine bone and along the lateral maxillary wall to the pterygoid plates. A gently curved osteotome was then used to separate the pterygoid plates from the distal aspect of the maxilla. Once this had been accomplished, a nasal septal osteotome was used to separate the nasal septum and vomer from the superior aspect of the maxilla.
Now, utilizing firm finger pressure, down-fracture maneuver was accomplished. The Le Fort I osteotomy was then mobilized to freely move it anteriorly. The greater palatine vessels were intact on both the right and left side. Further bone was removed from the superior portion of the maxilla to allow for free advancement. Rowe disimpaction forceps was used to freely mobilize the maxilla in all dimensions. At this time, a previously prepared acrylic intermediate splint was brought intraorally and the maxilla was brought into its anatomically determined occlusion and secured by the use of multiple 25 gauge stainless steel wires. The maxillomandibular complex was then superiorly repositioned into its appropriate anatomic relationship, having been advanced approximately 6 mm. A 1.7 mm titanium L-plate was adapted to the right and left piriform aperture and secured by the use of five 5 mm titanium bone screws of 1.7 mm diameter. In the posterior maxilla, 2-hole plates were contoured to fit across the osteotomy and these were 2 mm plates that were secured with two 2 x 5 mm titanium bone screws.
Once this had been accomplished, it was found that the maxilla had been rigidly stabilized. Prior to stabilization, the superior port of the maxilla along the nasal crest was smoothed with a rotating cutting instrument and a few millimeters of nasal septal cartilage was removed to allow for free repositioning of the maxilla and the soft tissue was closed by the use of interrupted and continuous running 4-0 Vicryl sutures. Now that the maxillary osteotomy had been well stabilized, the intermaxillary fixation was released, the intermediate splint was then removed, the oropharynx was suctioned free of all secretions and debris and the moist throat pack was removed about the endotracheal tube.
At this time, a previously prepared acrylic splint in its final jaw relationship was brought intraorally and tested on the dentition. At this time, attention was then directed to the right and left ramus areas where, by the use of an oscillating saw, a vertical osteotomy was completed, going from the greatest depth of the sigmoid notch down to the angle of the mandible. The proximal fragment was then brought laterally. Muscle attachments on the medial aspect were removed. Osteotomies were accomplished on both the right and left side. At this time, the mandible could be freely repositioned into its anatomically determined occlusion and the previously placed throat pack had been previously removed. The acrylic splint was used to reposition the mandible ideally into its anatomic location and the patient was secured into intermaxillary fixation utilizing multiple 25 gauge stainless steel wires.
Attention was then directed to the ramus area, where the inner aspect of the proximal segment was smooth with rotating cutting instruments so that the proximal segment laid passively against the distal segment. A 1.1 mm wire pass bur was used to place a transosseous wire through the lateral cortex of the distal segment through which a 26 gauge stainless steel wire was placed. This was passed around the posterior aspect of the proximal segment. The posterior segment was then gently but firmly seated into the glenoid fossa and this transosseous wire was tightened, to secure and stabilize the proximal segment to the lateral aspect of the distal segment. Once this wire had been placed and tightened, it was turned down into the bony crevice.
At this time, it appeared that both osteotomies had been positioned appropriately. At this time, a piece of iliac crest that had been procured from allogenic bone bank had been reconstituting in normal saline with a gram of Kefzol. The reconstitution was to fill any bone cavities and soften the bone for placement. An area on the anterior face of the maxilla measuring 23 x 5 x 5 mm was noted and a piece of this allogenic cadaver bone was cut into two segments that were 23 x 6 x 5 mm in height. This was shaped and contoured to fit the anterior face of the maxilla on both the right and left side. Two separate pieces were contoured. Once they had been contoured to fit, 2 mm stabilizing screws were placed, both 8 mm in length x 2 mm in diameter, to secure and stabilize the allogenic bone graft along the anterior face of the maxilla. This was accomplished on both the right and left side to 22 to 23 mm x 5 to 6 mm x 5 mm pieces of allogenic bone obtained from the allogenic cadaver iliac bone was placed on the maxilla and stabilized. The margins were re-contoured for proper facial balance.
At this time, the surgical area was irrigated with copious amounts of normal saline. A double skin hook was placed in the midline. A single skin hook was then used to grab the transverse nasalis muscle on both the right and left side, through which a 3-0 Ethibond suture was placed. This was tightened to re-anastomose the transverse nasalis muscle across the anterior part of the maxilla and floor of nose to help prevent widening of the alar base. Once this had been accomplished, a V-Y closure of the maxillary vestibular incision was accomplished utilizing interrupted and continuous running 3-0 Vicryl suturing. The V-portion was advanced toward the midline, approximately 5-10 mm and the Y-portion was closed by the use of interrupted 3-0 Vicryl suturing.
At this time, attention was directed to the ramus area on both the right and left side. The area was irrigated with copious amounts of normal saline. Medium Hemovac drains were placed bilaterally and the soft tissues closed by the use of interrupted and continuous running 3-0 chromic suture. Blood loss for the procedure was approximately 800 mL. Sponge count and needle counts were correct at the termination of the operation. The patient was administered Kefzol three times during the operation and dexamethasone 10 mg during the course of the operation. The patient tolerated the procedure well, was extubated in the operating room and transferred to the recovery area in a stable condition.
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