OT notes · OMFS

ORIF of mandible fracture (miniplate osteosynthesis)

Usual anaesthesia
General, with nasotracheal intubation and throat pack
Position
Supine, head ring, neck slightly extended
Setting
emergency

Operative note template for open reduction and internal fixation of mandible fractures with miniplates through an intraoral approach, with a filled example for a parasymphysis and contralateral angle fracture after a road traffic accident.

Download printable PDFFree. Just log in with your Google (Gmail) account.

Blank template

Follow this order in the case sheet. Tick the options that apply and fill the blanks.

Patient and case

  1. Name / Age / Sex
  2. UHID / IP no. / Ward-Bed
  3. Date of surgery / OT no.
  4. CaseElectiveEmergency (non-elective)if emergency, state urgency and reason
  5. Timesin OT ___ anaesthesia start ___ incision ___ closure ___ out of OT ___

Team

  1. Operating surgeonname, designation
  2. Assistant(s)
  3. Supervising consultantpresent in OT / available / not applicable
  4. Steps done by the residentwhole procedure / named steps, under whose supervision
  5. Anaesthetist
  6. Scrub nurse / circulating nurse

Diagnosis and procedure

  1. Pre-operative diagnosis
  2. Post-operative diagnosis
  3. Procedure planned
  4. Procedure performedif different from plan, state why
  5. Extra procedure done and reason'none' if none. Only to save life or health if not consented

Consent and safety checks

  1. Informed consentGeneralProcedure-specificHigh-riskAnaesthesiain a language the patient understands: language ___ witness ___
  2. Site / side markedYesNot applicable
  3. WHO Surgical Safety ChecklistSign inTime outSign out
  4. Antibiotic prophylaxisdrug, dose, route, time given before incision
  5. VTE prophylaxisMechanicalPharmacologicalNot indicated

Risks to explain in the consent for this operation

  • numbness of the lower lip and chin (mental or inferior alveolar nerve)
  • change in bite (malocclusion) needing elastics or re-operation
  • damage to tooth roots from screws
  • removal of a tooth in the fracture line
  • wound breakdown and plate exposure in the mouth
  • infection, non-union or delayed union
  • later removal of plates
  • sagging of the chin soft tissue after an anterior approach
  • weakness of the lower lip if a neck incision is needed (marginal mandibular nerve)

Pre-operative details for this operation

  1. Fracture sitesSymphysisParasymphysisBodyAngleRamusCondyleCoronoidside of each; displaced or not; favourable or unfavourable; open into mouth or not
  2. ImagingOPG, PA mandible, CT face; date
  3. Pre-injury occlusion and present occlusionderanged occlusion, step, open bite, deviation on opening
  4. Nerve status before surgerylip and chin sensation on each side (inferior alveolar / mental), marginal mandibular function
  5. Teeth in the fracture linetooth number, mobile, fractured root, periapical infection, impacted third molar
  6. Mouth opening and airwayinter-incisal opening in mm; plan for nasal intubation
  7. Associated injurieshead injury cleared, midface fractures, cervical spine
  8. Plating system availableplate thickness (e.g. 2.0 mm), hole counts, screw lengths, locking or non-locking

Anaesthesia and position

  1. AnaesthesiaGA, nasotracheal tubeGA, submental intubationGA, tracheostomy
  2. Throat packPlacedrecord placement so its removal can be checked
  3. PositionSupine, head ring
  4. Local infiltrationlocal anaesthetic with vasoconstrictor at incision sites; drug, strength and volume

Operative findings

  1. Fracture at each siteline, displacement, comminution, lingual split, soft tissue tear
  2. Mental nerve / inferior alveolar nerveSeen and intactStretchedTransectedNot seen
  3. Tooth in fracture lineRetainedExtractedreason
  4. Occlusion after fixation and release of IMFPre-injury occlusion achievedMinor discrepancy, elastics plannedNot achieved, refixed

Procedure (steps)

  1. Scrub, paint and drape; mouth irrigatedantiseptic used
  2. Intermaxillary fixation (IMF) appliedErich arch bars with circumdental wiresIMF screwsHybrid arch barsEyelet / Ivy loop wiringwire gauge, teeth from and to
  3. Incision for anterior fractureVestibular incision in lip mucosaGingival crevicularThrough existing lacerationSubmental (extraoral)distance from attached gingiva
  4. Mentalis and periosteum divided; mental nerves found and protectedside(s) seen
  5. Incision for posterior fractureVestibular incision along external oblique ridgeSubmandibular (Risdon)Retromandibular
  6. Fracture cleaned, reduced and patient put into IMFwires or elastics; reduction forceps if used
  7. Tooth in the fracture lineretained or extracted, with reason
  8. Fixation of anterior fracturenumber of plates, thickness, holes, screw type (mono or bicortical) and lengths, position relative to root apices and lower border
  9. Fixation of angle / body fractureSingle plate along Champy's line (superior border)Two platesLateral plate via transbuccal trocarplate, holes, screw lengths; trocar incision if used
  10. Reduction checkedlower border and lingual plate felt with elevator
  11. IMF released and occlusion checkedif not correct, plates removed and refixed
  12. Irrigation and haemostasis

Closure, drains and dressing

  1. Anterior woundmentalis muscle layer with interrupted absorbable; mucosa continuous absorbable
  2. Posterior intraoral woundsuture material and size
  3. Trocar / extraoral woundssuture and size
  4. Arch barsLeft in placeRemoved on table
  5. ElasticsNoneGuiding elasticsHeavy elastics
  6. Chin pressure dressingAppliedNot applied
  7. Throat pack removedYes

Specimens and implants

  1. Plates and screwsmake, material, plate thickness, holes, number and length of screws at each site; lot number; sticker pasted
  2. Arch bars and wirestype and wire gauge
  3. Extracted toothtooth number; discarded as anatomical waste or sent for HPE

End of procedure

  1. Estimated blood lossml
  2. IV fluids and blood / products givenfluids (ml); blood: type, units, bag nos.
  3. Swab, needle and instrument countCorrectIncorrect: action taken
  4. Intra-operative complications / difficultieswhat happened and what was done; 'none' if none
  5. Implant stickersNo implantAffixed in case sheet, OT register and for discharge summary
  6. Condition at end of surgery / shifted toPACUWardICU/HDU

Post-operative orders

  1. Airwaywire cutter or scissors at the bedside if in IMF or elastics
  2. Position and icehead end raised; ice packs to the face for the first 24 hours
  3. Antibiotics and analgesiadrug, dose, route, duration
  4. Oral hygienechlorhexidine or saline mouth rinses after feeds
  5. Dietliquids then soft diet; no chewing on hard food; dietitian if IMF beyond 2 weeks
  6. Elasticstype, how long
  7. Post-op imagingOPG and PA mandible
  8. Nerve checklip and chin sensation each side, recorded on POD 1
  9. Follow-up1, 3 and 6 weeks; arch bar removal plan at about 4 to 6 weeks

Signature

  1. Name and designation of person writing note
  2. Medical Council registration no.
  3. Signature / date / time of writingwrite before the patient leaves recovery

Worked example

Fictional case: Mr. R.P., 26 years, two-wheeler accident 2 days ago. Right parasymphysis fracture (between 43 and 44) and left angle fracture with partially erupted 38 in the fracture line. Deranged occlusion. Lower lip sensation normal on both sides.

Case details

Date: 18/05/2026. Emergency list. OT 4.

In OT 10:00. Induction 10:10. Incision 10:45. Closure completed 12:55.

Surgeon: Dr A. (MDS OMFS, 3rd year). Assistant: Dr B. (1st year). Consultant: Dr C., present in OT.

Anaesthetist: Dr D. Scrub nurse: Sr E.

Indication and pre-op

Indication: displaced right parasymphysis fracture and displaced unfavourable left angle fracture with deranged occlusion. OPG and CT face reviewed. No condylar or midface fracture.

Pre-op: lip and chin sensation normal both sides. Mouth opening 22 mm. 38 partially erupted, in fracture line, with pericoronal inflammation.

Head injury ruled out by neurosurgery. Consent: general, procedure-specific (lip numbness, bite change, removal of 38, plate removal later) and anaesthesia consent taken in Marathi.

WHO checklist done. Inj cefazolin 2 g IV and inj metronidazole 500 mg IV at induction.

Anaesthesia and position

GA with right nasotracheal tube. Throat pack placed. Supine on head ring.

Face painted and draped.

Local anaesthetic with vasoconstrictor infiltrated in the lower labial vestibule and left posterior vestibule.

Procedure

Upper and lower Erich arch bars fixed with 26-gauge circumdental wires, 16 to 26 and 36 to 46.

Anterior: mucosal incision in the lower lip, about 15 mm from the attached gingiva, canine to canine. Mentalis and periosteum divided. Right mental nerve found by blunt dissection and protected.

Findings: oblique fracture between 43 and 44, displaced 4 mm, lingual cortex intact. Mental nerve intact.

Fracture reduced with periosteal elevator and bone-holding forceps. IMF applied with 26-gauge wires.

Fixation: two 2.0 mm titanium miniplates. Upper plate 4-hole, about 5 mm below the root apices, monocortical screws 2.0 x 6 mm. Lower plate 4-hole near the lower border, bicortical screws 2.0 x 10 mm below the mandibular canal.

Posterior: incision along the left external oblique ridge, at least 15 mm from the mucogingival line. Full-thickness flap raised. 38 extracted without bone removal, socket curetted.

Angle fracture reduced. One 2.0 mm 6-hole miniplate along Champy's line at the superior border, monocortical 2.0 x 6 mm screws.

Lower border and lingual plate checked with a curved elevator: reduced.

IMF released. Occlusion checked: pre-injury occlusion achieved, mouth opens and closes without deviation.

Wounds irrigated with saline. Haemostasis secured.

Closure

Anterior: mentalis layer with interrupted polyglactin 910 (Vicryl) 3-0, mucosa continuous Vicryl 4-0.

Posterior: mucosa closed with interrupted Vicryl 4-0.

Arch bars left in place. Light guiding elastics not applied today. Chin pressure dressing applied.

Throat pack removed and count confirmed.

Specimens and implants

Implants: titanium 2.0 mm system, make as per sticker. Right parasymphysis: two 4-hole plates, 4 monocortical 6 mm and 4 bicortical 10 mm screws. Left angle: one 6-hole plate, 6 monocortical 6 mm screws. Lot numbers on sticker; stickers pasted in the case sheet and OT implant register.

Extracted 38 discarded as human anatomical waste (yellow bag). No HPE.

End of procedure

Estimated blood loss 150 ml. No transfusion.

Mop, needle and instrument count correct.

No intra-operative complications.

Extubated in OT, airway clear. Shifted to post-op ward in stable condition. Pulse 84/min, BP 124/76 mmHg.

Post-op orders

Head end up 30 degrees. Ice packs to face for 24 hours. Wire cutter at the bedside.

Inj cefazolin and metronidazole to continue as charted; analgesia as charted.

Chlorhexidine mouthwash after every feed. Clear liquids after 6 hours, then soft diet.

OPG and PA mandible on POD 1. Record lip and chin sensation on POD 1.

Review in OPD at 1, 3 and 6 weeks. Arch bar removal planned at about 4 to 6 weeks.

Signature

Dr A., MDS resident, OMFS. Reg. no. ________. 18/05/2026, 13:15.

Must document for this operation

  • Lip and chin sensation on each side before surgery and on POD 1. Numbness after mandible fixation is a common complaint, and without a pre-op record no one can say whether the injury or the operation caused it.
  • Occlusion achieved after the intermaxillary fixation (IMF) was released. Verifying the bite is the last step before closure, and a later malocclusion is judged against this entry.
  • Every plate and screw: site, thickness, holes, screw type and length, with the lot sticker. The surgeon who removes an infected or exposed plate needs this, and implant recalls are traced by lot number.
  • What was done with the tooth in the fracture line, and why. A retained tooth that later becomes infected, or a tooth removed without a recorded reason, is often questioned.
  • Mental nerve seen and protected, or its state if injured. Shows the nerve was looked for and records any injury found at surgery.
  • Throat pack placed and removed. A retained throat pack can block the airway after extubation.
  • Arch bars and elastics left in place, and the plan for their removal. The ward team must keep a wire cutter at the bedside and the OPD team must know when to remove them.

Common mistakes in these notes

  • Writing 'ORIF done with miniplates' without the site, hole count and screw lengths.
  • No record of lip sensation before surgery.
  • Not writing that occlusion was checked after release of IMF.
  • Leaving out the tooth in the fracture line.
  • Not recording the throat pack.
  • Implant sticker not pasted, or pasted without the site it belongs to.

Indian practice and paperwork

  • The batch and serial number of every implant must be recorded in the patient's record, the OT master logbook and the discharge summary. This covers mandible plates and screws. (NABH 5th ed., MOM.10(d))
  • An extracted tooth is human anatomical waste and goes in the yellow bag if not sent for HPE. (Bio-Medical Waste Management Rules 2016, DGHS/CPCB guidelines, Yellow (a))
  • An audit at JIPMER, Puducherry, found that a computerised OMFS proforma with diagram sheets raised the completeness of operative notes from 84.6% to 98.4% of data points. Drawing the fractures and plates on a diagram is a quick way to record plate positions. (Krishnan B, Prasad GA, Madhan B. J Maxillofac Oral Surg 2016;15(3):315-320, PMID 27752200)
  • The operative note must be written before the patient leaves recovery. (NABH 5th ed., COP.14(e))

Sources

  • Haggerty CJ, Laughlin RM, eds. Atlas of Operative Oral and Maxillofacial Surgery. 2nd ed. Wiley; 2023, Ch 17, Mandibular Fractures (Haggerty CJ): anterior and posterior mandibular fractures, pp. 254-263.
  • Perry M, Holmes S, eds. Atlas of Operative Maxillofacial Trauma Surgery: Primary Repair of Facial Injuries. Springer London; 2014, Ch 3.2 Temporary stabilisation and IMF; Ch 4.6 Applying semirigid fixation; Ch 6 Mandibular Fractures, 6.5-6.6, pp. 98-111, 128-129, 169-205.
  • Bratzler DW, et al. Clinical practice guidelines for antimicrobial prophylaxis in surgery. Am J Health Syst Pharm. 2013;70(3):195-283. Head and neck clean-contaminated procedures: cefazolin + metronidazole. Table 1 adult doses: cefazolin 2 g (3 g if 120 kg or more), metronidazole 500 mg, within 60 min before incision. academic.oup.com/ajhp/article/70/3/195/5112717

Educational template for residents. Adapt it to your institution's case-sheet format and your consultant's instructions. Patient details in the example are fictional.

Videos of this operation

Teaching videos and pages for this operation, listed under the curriculum item that asks for it.

This page cannot be printed from the browser. Use the Download printable PDF button on the page.