Mandibular Swing Approach via Paramedian Mandibulotomy for Surgical Access to an Inaccessible Tongue Lesion: A Case Report and Review of Literature

Abstract

The surgical management of deeply situated oral cavity lesions is challenging, particularly when transoral access is limited by tumour location or restricted mouth opening. The paramedian mandibulotomy approach, first described by Roux in 1836 and refined over time, provides optimal exposure for lesions in the oral cavity, oropharynx, and parapharyngeal space while preserving mandibular function and neurovascular integrity. This case report describes a 52-year-old male with a non-healing tongue ulcer and restricted mouth opening, necessitating a lip-split paramedian mandibulotomy for tumour excision. The osteotomy, performed between the canine and first premolar, incorporated a step-design and pre-adapted miniplates to ensure precise anatomical realignment and stability. The technique facilitated en bloc resection with adequate margins and maintained occlusal function without complications. Compared to midline or lateral approaches, the paramedian mandibulotomy minimizes morbidity by preserving muscle function and reducing risks of malocclusion, osteoradionecrosis, and sensory deficits. Literature supports its efficacy in complex head and neck oncology, offering superior exposure for tumour resection while enabling simultaneous neck dissection access. This approach remains a reliable option for deep-seated lesions, particularly in patients with restricted mouth opening, balancing oncological safety with functional preservation. Preoperative planning, meticulous osteotomy design, and plate pre-adaptation are critical to optimizing outcomes.