A salvage procedure (partial mandibulectomy or incisivectomy) involves a complete removal of the affected bone and teeth with closure of the soft tissues. A comfortable and functional bite is achieved.
An incisivectomy is indicated when a fracture of the bone holding the incisor teeth is not repairable.
The gingiva is incised in areas that are still attached. Periosteal elevators are used to remove all the attachments.
The area is inspected and radiographed prior to closure to ensure complete debridement of the fragments and removal of fractured dental roots.
Closure of the flap can be done in one or two layers using a 4-0 poliglecaprone 25, or other monofilament absorbable suture, in a simple interrupted fashion. To avoid tension on the suture line, undermining of the surrounding tissues may be needed.
Bilateral cheiloplasty (commonly referred to as fish-mouth procedure) may be needed after partial removal of the mandible. Cheiloplasty reduces the loss of food and saliva from the mouth and provides support for the tongue.
This procedure is most commonly needed in small breed dogs and cats.
Bone and infected soft tissue removal
The bone and the infected soft tissue are removed.
The wound is irrigated with sterile saline 0.9%.
The oral mucosa is closed using 4-0 poliglecaprone 25 in a simple interrupted fashion.
Mucocutaneous junction removal
The mucocutaneous margins are marked with a sterile marking pen on the upper and lower lip, about half way between the commissure of the lips and the nose.
The marked line is at 2-3 mm of distance from the mucocutaneous junction.
Stay sutures are placed at the rostral aspects of the incision to apply tension and provide landmarks for the rostral aspects of the incision.
2-3mm of the mucocutaneous margin are resected along the marked line using a sharp scalpel blade. Sharp scissors can be used after the initial incision to remove the mucocutaneous junction.
The mucosae of the upper and lower lip are sutured together using 4-0 poliglecaprone in a simple interrupted fashion.
The submucosa and subcutaneous tissues are closed using 4-0 poliglecaprone in a simple interrupted fashion, followed by skin closure using 4-0 monofilament nonabsorbable in a simple interrupted fashion.
5. Case example - ‘Fish – mouth’ salvage procedure
Removal of the infected mandibular bone segment in a small breed dog.
Postsurgical appearance after "Fish-mouth" salvage procedure.
The patient should wear an Elizabethan collar until removal of the construct.
Multimodal analgesia is recommended. Non-steroidal medication for 10-14 days and opioids for the first 5 days post-surgery as needed.
Antibiotic therapy is prescribed for a period of 10-14 days following surgery.
Soft food should be fed for the first 14 days, followed by a gradual return to eating kibble over 2 weeks.
The soft tissues should be cleaned at least once daily using 0.12% chlorhexidine gluconate solution. Another option is to use a water-flossing device.
Rough play (i.e., tug of war) should be avoided for the first 3 months after surgery.
Suture removal is recommended in 10-14 days and recheck examinations at three and six months postoperatively.