Step 2 Incision

In the anterior region, from canine to canine, the lower lip is everted and a scalpel or electrocautery is used to incise the mucosa. The incision is curvilinear, extending anteriorly out into the lip, leaving 10 to 15 mm of mucosa attached to the gingiva. Once through the mucosa, the underlying mentalis muscle are clearly visible ( Fig. 8-5). The muscle fibers are sharply incised in an oblique approach to the mandible (Fig. 8-6). When bone is encountered, an ample amount of mentalis muscle should remain on its origin for holding deep sutures at closure.

FIGURE 8- 5 Incision through the oral mucosa in the anterior region is out in the lip, exposing the underlying mentalis muscle fibers.

In the body and posterior portion of the mandible, the incision is placed 3 to 5 mm inferior to the mucogingival junction. Leaving unattached mucosa on the alveolus facilitates closure. Any incision placed more inferior in the canine/premolar region may sever branches of the mental nerve. The scalpel should be perpendicular to bone when incising above the mental foramen to prevent incision of this nerve.

The posterior extend of the incision is made over the external oblique ridge, traversing mucosa, submucosa, buccinator muscle, buccopharyngeal fascia, and periosteum (see Fig. 8-5). The incision is usually no more superior then the occlusal plane of the mandibular teeth to help prevent herniation of the buccal fat pad into the surgical field, a nuisance during surgery. The buccal portion of the buccal fat pad is usually not more inferior than the level of the occlusal plane (see Fig 8-4). Placement of the incision at this level also may spare severing the buccal artery and nerve, although damage to them is more a nuisance than a clinical problem. If the buccal artery is severed, it is easily controlled by coagulation.

In the edentulous mandible, the incision is made along the alveolar crest, splitting the attached gingiva. This placement facilitates closure and minimizes risk to the mental nerve. Alveolar atrophy brings the inferior alveolar neurovascular bundle and the mental foramen to the superior surface of the bone. In these instances, crestal incision behind and in front of the mental foramen, which is easily located by palpation, are joined following subperiosteal dissection to identify the exact location of the mental nerve. Posteriorly, the incision leaves the crest at the second molar region and extends laterally to avoid the lingual nerve, which may be directly over the third molar area. Placing the incision over the ascending ramus helps to avoid the lingual nerve.

FIGURE 8- 6 Cross section of the symphysis showing the path of dissection

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