Step 5 Division of the Pterygomasseteric Sling and Submasseteric Dissection

After retraction of the dissected tissues anteriorly (the marginal mandibular branch of the facial nerve perhaps under the retractor), a broad retractor such as a ribbon is placed behind the posterior border of the mandible to retract the mandibular tissues medially. The posterior border of the mandible with the overlying pterygomasseteric sling is visualized (Fig. 10-7). The pterygomasseteric sling is sharply incised with a scalpel (Fig. 10-8). The incision begins as far superiorly as is reachable and extends as far inferiorly around the gonial angle as possible. An incision in the posterior portion of the sling bleeds less than an incision placed more laterally through the belly of the masseter muscle.

Temporalis Muscle Sling

Figure 10-7 The surgical window to the posterior mandible is revealed by retraction of tissues between inferior (*) and posterior divisions of VII. The retractor is on the neck of the condyle (*). Note the path of the retromandibular vein (RV). The inferior division of VII can be retracted farther inferiorly to allow access to the gonial angle.

Figure 10-7 The surgical window to the posterior mandible is revealed by retraction of tissues between inferior (*) and posterior divisions of VII. The retractor is on the neck of the condyle (*). Note the path of the retromandibular vein (RV). The inferior division of VII can be retracted farther inferiorly to allow access to the gonial angle.

Vein Sling
Figure 10-8 Incision through the pterygomasseteric sling along the posterior border of the mandible. The inferior division of VII is being retracted superiorly.

The sharp end of a periosteal elevator is draw along the length of the incision to begin stripping the tissues from the posterior border of the ramus. The masseter is stripped from the lateral surface of the mandible using periosteal elevators. Clean dissection is facilitated by stripping the muscle from top to bottom (Fig 10-9). Keeping the elevator in intimate contact with the bone reduces shredding and bleeding of the masseter. The entire lateral surface of the mandibular ramus to the level of the temporomandibular joint capsule as well as the coronoid process can be exposed. Retraction of the masseter muscle is facilitated by inserting a suitable retractor into the sigmoid notch (channel retractor, sigmoid notch retractor)(Figs. 10-10 to 10-12).

Figure 1 2 10-9 Subperiosteal dissection of the masseter muscle. The periosteal elevator is used to strip the muscle fibers from the top to the bottom of the ramus.
Pterygomasseteric Sling

Figure 1 3 10-10 Sigmoid notch retractor. The curved flange at the end is inserted into the sigmoid notch, retracting the masseter muscle.

Figure 1 4 10-11 Exposure of the posterior ramus. The sigmoid notch retractor is placed into the sigmoid notch, elevating the masseter, parotid, and superficial tissues.
Masseter Temporalis Joint
Figure 10-12 Anatomic dissection showing exposure of the posterior ramus with retraction of the superior division of VII by the channel retractor (*). + = marginal mandibular branch VII; RV = retromandibular vein

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Responses

  • mikko
    What is a pterygomasseteric sling?
    3 years ago
  • matilda
    What is pterygomasseteric sling fibers?
    7 months ago

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