Compression-distraction osteosynthesis of facial bones in children

The lower jaw is subject to traumatic damage much more often than other bones of the facial part of the skull. Although it is one of the strongest bones, its mobility and protruding position make it susceptible to fractures. Up to 85% of all injuries to facial bones occur due to fractures of the lower jaw. These figures include both isolated fractures of the lower jaw and fractures with simultaneous damage to other bones of the facial skeleton.

Experts predict that the number of injuries to the lower jaw will only increase, as well as the nature of such injuries. This is facilitated by an increase in the number of vehicles, an increase in their speed limits, as well as complex technical equipment in production.

Types and localization of mandibular fractures

Non-gunshot, most often linear fractures of the mandible occur in the area of ​​the condylar process, the angle of the mandible, the central incisors, the canine and the mental foramen. These places are usually called “places of weakness.”

Direct fractures of the mandible occur at the site of application of force.

Reflected fractures are localized due to the direction of impact and the area of ​​damage. For example, as a result of a lateral impact, a reflected unilateral fracture of the neck of the lower jaw often occurs. The maximum tension in the bone tissue in the midline area is created due to bilateral compression of the mandibular bone in the region of the molars (sixth, seventh and eighth teeth).

How the fragments will be located during a fracture of the lower jaw depends on several factors. These include: the strength of the damaging factor, the volume of the injured area, as well as muscle groups attached to the surface of the injured area.

Indications for closed focal osteosynthesis

Closed focal osteosynthesis can be used as a treatment for the jaw if the fragments in a non-displaced fracture can be easily reduced by hand.

Indications for the use of Kirschner wires during osteosynthesis are all minor jaw fractures with the possibility of fixing fragments using wires. In this case, the length of the spoke in the fragment should be at least 3 centimeters.

If the fracture gap is significantly tilted in the anteroposterior direction, closed osteosynthesis with a surrounding suture is indicated. The suture is made in such a way that the fragments are tightly compressed in the vertical direction and do not subsequently move relative to each other. Sometimes this method of osteosynthesis is supplemented by the application of a dentogingival prosthesis.

Causes of mandibular fractures

Mandibular injuries are divided into four types:

1. Domestic injuries that arise from conflicts in everyday life or doing housework.

2. Street injuries resulting from the use of vehicles, and street injuries not related to damage in transport. This could be a fall while walking due to ice, other bad weather, or poor health.

3. Sports injuries received while playing sports.

4. Industrial injuries sustained in industrial production in agriculture.

Symptoms of a mandibular fracture

With a fracture of the lower jaw, patients may complain of impaired or limited mobility of the lower jaw, pain that may intensify with movement, biting or chewing, malocclusion, changes in the sensitivity of the skin on the lower lip or chin, bleeding from the oral cavity - a symptom characteristic of ruptures of the mucous membrane .

The range of complaints that the patient presents helps the doctor understand what kind of damage is being discussed and suggest the location of the fracture.

Diagnosis of mandibular fractures

Diagnosis is based on examination data and collection of patient complaints.

During the examination, the doctor pays attention to the condition of the skin, notes whether the patient has bruises, abrasions or wounds, and records the presence of hyperemia, cyanosis and bruising. Notes the presence of asymmetry on the damaged side of the face.

If a fracture of the lower jaw is suspected, the doctor first feels the undamaged area with his fingertips, and then the damaged one. He marks the places of greatest pain, unevenness, violation of integrity, determines the amplitude of movement of the head of the lower jaw in the articular cavity - for this, the doctor places the tip of his finger in the external auditory canal. The doctor determines the condition of the head of the lower jaw or its displacement by palpating the surface in front of the tragus of the ear both in motion and at rest.

Violation of the integrity of the lower jaw confirms a number of symptoms associated with pain in the fracture area:

Symptom of referred pain

(indirect load), in which pain in the fracture area occurs in response to finger pressure on the chin.

Spatula symptom

provokes pain at the site of the jaw fracture, both lower and upper. To do this, a wooden spatula is placed between the patient's teeth, after which the teeth are closed, and the doctor makes a small blow to the outer part of the spatula.

The occurrence of pain with simultaneous pressure and bringing together the angles of the lower jaw may indicate a fracture of the chin.

Impaired pain and tactile sensitivity of the skin of the lower lip and chin may indicate damage to the lower alveolar nerve.

Fractures of the lower jaw are characterized by a change in bite (the teeth of the upper and lower jaws do not close together correctly), which depends on the nature and location of the fracture.

Thus, with a unilateral fracture in the area of ​​the body or angle of the lower jaw, the closure of the teeth will occur on a small fragment.

A unilateral fracture with displacement of the condylar processes is characterized by closure of the molars only on the damaged side, and no contact occurs on the undamaged side.

With a bilateral fracture of the angles or body of the lower jaw, contact is possible between the molars, while the front teeth cannot close - the patient has an open bite.

For a fracture in the central part of the lower jaw, malocclusion may not occur. But if there is displacement of the fragments, the patient will have a tilt of the chewing teeth towards the tongue (tubercular contact).

A change in bite may also be indicated by a shift in the midline between the central incisors on the upper and lower jaws, and a mismatch in the position of the frenulum of the upper and lower lips.

Examination of the oral cavity helps to find breaks in the mucous membrane of the alveolar process, as well as to detect hemorrhages in the area of ​​the transitional fold (often with exposure of bone). Palpation allows you to determine the location of sharp edges under the mucous membrane and confirms abnormal mobility of the lower jaw. If there are displaced fragments, the doctor visually fixes the neck or root of the tooth in the fracture line.

After examination, the nature and location of the fracture is confirmed using X-rays (pictures are taken in frontal and lateral projections) or using multispiral computed tomography. Orthopantomography does not always allow one image to see all the changes that occur due to trauma to the lower jaw. It should be noted that for fractures in the area of ​​the angle, if the fragments are displaced outward, the orthopantomogram may not show the displacement. It should be considered as two lateral radiographs, to which it is necessary to additionally take a radiograph in a frontal projection.

Pictures obtained by orthopantomography can be used as lateral projections, but always require an additional AP picture obtained using radiography.

The x-ray image better shows the violation of the integrity of the bone tissue, the presence of a tooth root in the fracture gap.

After an imaging test, the doctor makes a final diagnosis and determines a treatment plan for the patient.

Introduction

Injuries to the maxillofacial region continue to remain one of the pressing surgical problems, which is associated with an increase in the number of patients with fractures of the facial skull bones as a result of road accidents and domestic conflicts, the aggravation of this type of pathology, and the increase in multiple and combined injuries [1, 2]. According to specialized literature, the share of maxillofacial trauma in the structure of various injuries among the urban population is 3.2–8.0% [3]. Fractures of the lower jaw account for up to 85% of the total number of fractures of the facial skull [4–7]. The development and implementation of new methods for fixing bone fragments have significantly increased the effectiveness of surgical treatment in the category of patients under discussion; however, according to a number of authors, complications range from 5.2 to 38.4% of cases [8–11].

Many of the proposed methods are successfully used in everyday practice for performing osteosynthesis for facial skull fractures - titanium plates on the bone, bone suture with stainless steel or tantalum wire, Kirschner wires, a possible combination of bone suture and wires, fixing structures made of shape memory materials. The purpose of this article is to describe the clinical use of titanium nickelide (nitinol) shape memory brackets for mandibular angular fractures.

Clinical case

Patient T.

, 41 years old, was admitted to the clinic of maxillofacial surgery of the University Clinical Hospital (UCH) No. 2 of the First Moscow State Medical University named after. THEM. Sechenov with complaints of pain in the lower jaw on the right, aggravated by chewing and opening the mouth, swelling of the face on the right, and malocclusion.

From the anamnesis it was established that the injury was received as a result of a fight with an unknown person 8 hours before going to the hospital. The patient did not report any compression phenomena. He went to the trauma center, where an X-ray of the skull and intermaxillary fixation were performed using Tigerstedt dental splints. The patient was taken by an ambulance team to the clinic of Clinical Hospital No. 2 of the First Moscow State Medical University named after. THEM. Sechenov, was hospitalized on an emergency basis.

On admission: general condition is relatively satisfactory. Somatic status without features. Upon examination, pronounced swelling of the soft tissues in the parotid-masticatory, buccal and submandibular areas on the right was determined. It was difficult to gather the skin into a fold; local pain was noted on palpation. Regional lymph nodes are not enlarged. The symptom of direct and indirect load is positive in the area of ​​the angle of the lower jaw on the right. Vincent's sign was positive on the right side. From the side of the oral cavity: opening is limited to 2 cm, there was a violation of the closure of teeth such as an open bite on the right. Ruptures in the mucous membrane of the alveolar part of the lower jaw in the area of ​​4.7–4.8 teeth, as well as the presence of hemorrhagic clots in the oral cavity, were visualized. Swallowing is free, moderately painful (Fig. 1, 2,

Rice. 1. Patient T.’s appearance during hospitalization.

Rice. 2. Orthopantomogram of patient T. during hospitalization. There is a violation of the integrity of the bone tissue in the area of ​​the angle of the lower jaw on the right with the presence of tooth 4.8 in the fracture line. 3).

Rice. 3. X-ray of the skull of patient T. in a direct projection.

Based on complaints, anamnesis, clinical examination and x-ray examination, the diagnosis was made: “Fracture of the lower jaw in the area of ​​the angle on the right with displacement of fragments.”

After additional examination and preoperative preparation, on the day of admission to the hospital, the patient underwent surgical intervention: osteosynthesis of the lower jaw in the area of ​​the right angle using external access using titanium nickelide brackets.

The operation was performed as follows: with premedication under local anesthesia with Sol. Lidocaini 1% 20 ml, on the side of the fracture parallel to the edge of the lower jaw, retreating 2 cm in the area of ​​the angle, a skin incision 4 cm long was made. The skin, subcutaneous fat, superficial fascia of the neck and m. Platisma. The masticatory muscle itself was cut off at the point of attachment to the angle of the lower jaw. The lower jaw in the area of ​​the angle is skeletonized. After visualization of the fracture line, small bone fragments were removed, soft tissue interposition was eliminated, and blood clots were removed. Before performing osteosynthesis of the lower jaw, a loose bone fragment and tooth 4.8 were removed from the fracture line (Fig. 4),

Rice. 4. A removed bone fragment not connected to the periosteum, and tooth 4.8 from the fracture line. Reposition of bone fragments was performed. The bite was fixed in the patient’s usual position using rubber rods and osteosynthesis was performed using two Ω- and S-shaped titanium nickelide brackets under bite control (Fig. 5).

Rice. 5. Operation stage. Osteosynthesis of the lower jaw using Ω- and S-shaped titanium nickelide brackets.

The brackets were installed as follows: holes were formed bicortically on each fragment using a drill, then the legs of the bracket, pre-cooled to +1-3 °C, were bent to the sides (the bracket was activated) and inserted into the corresponding milling holes. When the bracket was heated to 35-36 °C, the original shape was restored - the legs of the bracket were brought closer together, which led to dosed compression of the bone fragments. The postoperative wound was treated with antiseptic solutions, and a latex graduate was installed. The wound was sutured in layers. Hemostasis was performed during the operation.

The postoperative period was uneventful. The patient was discharged for outpatient observation on the 7th day after surgery, after removal of the sutures. Mouth opening at the time of discharge was 3.0 cm.

On the 2nd day after surgery, control radiographs of the skull in a direct projection and orthopantomography were performed. The position of the bone fragments and fixation structures was correct, no secondary displacements were detected (Fig. 6,

Rice. 6. Orthopantomogram of patient T. after surgical treatment. 7).

Rice. 7. X-ray of the skull of patient T. in a direct projection after surgical treatment.

During a follow-up examination after 1 month, an increase in mouth opening to 4.2 cm was noted; the patient’s chewing function and appearance were completely restored (Fig. 8).

Rice. 8. a — appearance of patient T. 1 month after surgery; b — amplitude of mouth opening of patient T. 1 month after surgery. As a result of dynamic observation and interdisciplinary treatment together with a physiotherapist, the prescription of physiotherapy and vitamin therapy on the affected side, the sensitivity of the skin and teeth in the zone of innervation of the inferior alveolar nerve was restored after 6 months.

Over a three-year observation period with examinations once every 6 months, a stable state of occlusion, absence of pain in the lower jaw and neuropathy of the inferior alveolar nerve were noted.

First aid for fractures of the lower jaw

It can be carried out either at the scene of the incident or in an ambulance. It can be provided by both medical and non-medical workers in the form of mutual assistance.

The victim’s damaged jaw is temporarily (for several hours) fixed (the upper jaw is pressed to the lower) using bandages or other devices in order to be able to deliver him to a medical facility.

For fixation, the following can be used: a circular bandage parietal-mental bandage, a soft chin sling (Pomerantseva - Urbanskaya), an Entin splint (standard transport rigid bandage), as well as various types of intermaxillary ligature binding. If the patient has a traumatic brain injury, ligature binding is used with extreme caution - fixed jaws do not allow opening the mouth, and can lead to aspiration of vomit or blood.

Technique of intraosseous (immersion osteosynthesis)

Open and closed surgery is performed depending on the severity of the fracture.
In a closed operation, bone fragments are first compared using a device. At the next stage, a metal rod is smoothly inserted into the body of the tubular bone. To do this, specialists use x-rays to achieve 100% accuracy. The final stage is the removal of the conductor and the application of surgical sutures. Open surgery is performed after opening the tissue. The fragments are evenly fixed with a surgical instrument (special devices are not used). This method is more effective, but more traumatic. Damage to soft tissues, extensive blood loss and the likelihood of infection force patients to abandon this method.

Permanent fixation of fragments

Fragments of the lower jaw can be fixed using conservative and surgical methods.

Permanent fixation can be carried out using: steel standard tape splints (Vasiliev splints), Tigerstedt dental wire splints, dental dentogingival and supragingival plastic splints, which are made in dental laboratories (they are rarely used nowadays).

In recent years, some clinics have begun to use orthodontic screws, which are inserted through the mucosa into the alveolar processes of the jaws, 3 pieces on each side, after which a rubber rod is put on the heads of the screws, providing intermaxillary fixation. This avoids the time-consuming procedure of double-jaw splinting. On the other hand, when inserting screws, the roots of the teeth can be damaged; in addition, there are often situations when the screw, under the action of a rubber rod, becomes mobile, which leads to inadequate intermaxillary fixation and removal of the screw.

If conservative treatment methods do not produce an effect, osteosynthesis is used - this is a surgical method that, with the help of devices, allows you to fix the fragments and eliminate their mobility. Osteosynthesis is performed if the patient has comminuted fractures of the lower jaw, or the displacement of the fragments is so pronounced that they do not allow closed reduction. Osteosynthesis is also indicated in the absence or insufficient number of teeth in the patient.

Approximately 30% of patients with mandibular fractures require surgical treatment. Currently, osteosynthesis is one of the leading methods of surgical care, and is used much more often than in the past.

This is due both to an increase in the arsenal of technical means for performing surgery (the presence of physiodispensers, titanium miniplates), which leads to improved surgical techniques, greater predictability of results, and to the requests of patients, which are aimed at a more comfortable course of the post-traumatic period, reducing the time of intermaxillary fixation, and in some cases, complete abandonment of it.

Methods for treating fractures using surgical techniques make it possible to compare and fix mobile bone fragments in a normal anatomical position. This helps reduce treatment time and achieve early restoration of lower jaw function. However, according to various data from Russian and foreign clinics, there is also a negative aspect of using osteosynthesis - about 30% of patients experience complications after using this technique. This is due to the use of materials to hold fragments: steel, titanium, etc. Even the most bioinert alloys are not ideal. Being in bone tissue, they undergo corrosion and cause galvanosis, which negatively affects the recovery process and can cause purulent-inflammatory complications and pain reactions.

Compression-distraction osteosynthesis of facial bones in children

Currently, the number of children with congenital and acquired defects and deformities of the maxillofacial area has increased. In this case, vital functions such as breathing, vision, chewing, swallowing, and speech are disrupted. With severe underdevelopment of the lower jaw in children, the root of the tongue moves posteriorly and narrows the lumen of the upper respiratory tract, resulting in breathing problems, more often during sleep, which can lead to the death of the child. Children with cosmetic defects become shy, depressed, secretive, and uncommunicative. In addition, serious mental suffering leads to their aggressiveness and bitterness. Underdevelopment and defects of individual facial bones that are not corrected in childhood cause gross secondary deformations, which are not always and are difficult to correct at an older age.

Today, there is no single surgical treatment method that can reliably eliminate various facial deformities associated with underdevelopment and defects of the skull bones. Osteoplastic operations performed using various types of grafts, titanium plates, biocomposites, silicone are not reliable enough in eliminating deformations, defects and underdevelopment of the bones of the facial skeleton and are often unacceptable for children of different ages. With the simultaneous movement of the bones of the midface, in addition to relapses, more severe complications arise: significant profuse bleeding, partial necrosis of bone fragments and even deaths.

In the last decade, the method of compression-distraction osteosynthesis (CDO) in the maxillofacial area has been intensively developed in the world, since this method does not lead to the development of complications that arise when performing bone grafting (Habal MB, 1995; McCormick SU, 1995; Cohen SR, 1995; Polley J., 1995; Mo na ste rio O., Mo li na F., 1997; Klein C., 1998; Boz zet ti

A. et al., 2001; Mi no ru U., 2001; Moli na F., 2004; Ha ra da K., 2007).

To date, quite a lot of treatment methods and compression-distraction devices (CDAs) have been developed for children with underdevelopment and defects of the lower jaw (Roginsky V.V. et al., 2001, 2002, 2007).

In 1954 G.A. Ilizarov proposed a method for treating patients with various congenital and acquired deformities of long bones.

Carrying out EDT is possible only with the use of CDA. The bulkiness of domestic distraction devices and the complexity of their manufacture have led to the fact that in our country CDO has not received proper development, as a result, for many years, thousands of patients have not received high-quality, comprehensive treatment. The lag behind Western countries, despite the domestic priority of KW, was 20-30 years. The need for this type of help among Moscow children alone is about 500 people a year, and in Russia as a whole it is several hundred thousand people.

Despite the fact that CDO is successfully used all over the world to treat adult patients, many important unresolved issues remain regarding the treatment of children: the distraction mode depending on the pathology zone; age at which this method can be used; the need to develop the most

gentle methods of surgical interventions to individual areas of the facial skeleton; lack of clear indications and contraindications for the use of the method and the use of various types of CDA. In addition, it is still not clear how CDA affects the morphogenesis of tissues of the maxillofacial region in children during their growth; the most reliable and easy-to-use CDA, which can reduce the percentage of complications, have not been developed.

Indications for the use of medical technology

Using KDO on the lower jaw:

1. Underdevelopment of the branch and/or body of the lower jaw, accompanied by disocclusion.

2. Defect of the body or branch of the lower jaw.

3. Respiratory obstruction syndrome, as a consequence of severe underdevelopment of the lower jaw.

4. Combined underdevelopment of the lower and upper jaws.

5. Underdevelopment of the chin of the lower jaw.

Using KDO on the upper jaw:

1. Upper retromicrognathia.

2. Facial deformation in the frontal region of the upper jaw.

Using KDO on the middle zone of the face:

1. Exophthalmos, as a consequence of underdevelopment of the zygomatic-orbital complex.

Contraindications to the use of medical technology

1. Allergic reactions to metal.

2. Osteoporosis.

3. Severe mental disorders.

Logistics support for medical technology

1. A set of titanium assemblies and parts for assembling intraoral compression-distraction devices for the correction of congenital and acquired defects and deformations of the upper and lower jaws and instruments for installing NUD-KD/TMJ - “Konmet” (Russia). Registration certificate FS No. 022a4337/098704 dated December 20, 2004

2. A set of titanium components and parts for assembling external fixation and distraction devices for fractures and deformations of the lower jaw, instruments and devices for their installation, NUD-FD/NC - “Konmet” (Russia). Registration certificate FS No. 022a4339/0988-04 dated December 20, 2004

3. A set of titanium components and parts for assembling distraction external fixation devices for fractures of the bones of the midface and upper jaw and tools for their installation, NE-D/SZVCH - “Konmet” (Russia). Registration certificate FS No. 022a4338/0989-04 dated December 20, 2004

Description of medical technology

A method for eliminating underdevelopment and/or defect of the lower jaw, combined with underdevelopment of the upper jaw (RF Patent for invention No. 2267303).

Preparing patients for planned surgery is carried out according to general rules: general blood test with hemosyndrome, blood group and Rh factor, biochemical blood test, general urinalysis, electrocardiogram. The main stages of the preoperative examination are X-ray (teleradiograms in two projections, orthopantomogram, computed tomography), cephalometry, photo documentation.

The operation is performed under endotracheal anesthesia. Using an incision up to 6 cm in the oral cavity along the transitional fold on the affected side, the branch of the lower jaw is skeletonized. The osteotomy line is marked: the outer cortical layer is sawed with a bur or saw, and the outer and inner cortical plates are sawed along the anterior and posterior edges of the lower jaw branch (the inner cortical plate in the middle part is preserved). An intraoral on-bone CDA is installed, previously untwisted by 2 - 3 mm, so that compression can subsequently be carried out. Using a drill with a diameter of 1.6 mm, create holes for the screws. Holes are drilled through 2 cortical layers. The depth gauge determines the length of the holes. Based on this, self-tapping screws of the required length with a diameter of 2 mm are selected. The device is fixed to the bone fragments so that the screws pass through 2 cortical layers. The screws are tightened until they stop. An osteotome is used to break the inner cortical plate. Compression of bone fragments is carried out. Hemostasis is carried out during the operation. The wound is sutured in layers.

Then an incision is made along the transitional fold from the tubercle of the upper jaw on one side to the tubercle of the opposite side. The upper jaw is skeletonized on both sides. An intraoral to bone KDA is fixed to the upper jaw on the affected side with at least 12 screws with a diameter of 2 mm and a length of no more than 5-7 mm. The device is fixed at an angle to the midline so that during distraction it ensures the divergence of bone fragments in the form of a wedge, the apex of which is located in the area of ​​the zygomaticalveolar crest of the healthy side. An osteotomy of the vomer, as well as the upper jaw, is performed at the level of the pyriform foramina on both sides with an osteotomy in the area of ​​the pterygomaxillary joint on the healthy and affected side (Fig. 1). Compression is in progress. Hemostasis is carried out during the operation. The wound is sutured in layers.

Rice. 1. Schemes of the developed technique: a - operation; b - the result obtained.

In the postoperative period, antibacterial therapy, rinsing the mouth with an antiseptic solution, and daily change of aseptic dressings are carried out. Distraction of the lower jaw begins on the 5th day after surgery, 1 mm per day in 4 doses of 0.25 mm; distraction of the upper jaw - on the 10th day, 0.5 mm per day in 2 doses of 0.25 mm. The retention period lasts at least 12 weeks.

Method for eliminating underdevelopment of the chin of the lower jaw (RF Patent for invention No. 2268016).

Preparing patients for a planned operation is carried out according to general rules: general blood test with hemosyndrome, blood group and Rh factor, biochemical blood test, general urinalysis, electrocardiogram. The main stages of the preoperative examination are X-ray (teleradiograms in two projections, orthopantomogram, computed tomography), cephalometry, photo documentation.

The operation is performed under endotracheal anesthesia. Using an incision in the oral cavity along the transitional fold from the retromolar region of one side to the retromolar region of the other side, the body of the lower jaw is skeletonized on both sides. The neurovascular bundle is carefully mobilized on both sides. In the area of ​​the angle of the lower jaw, a CDA is installed parallel to the lower edge of the body, previously untwisted by 1-2 mm, so that compression can subsequently be carried out. Using a drill with a diameter of 1.6 mm, create holes for the screws. Holes are drilled through 2 cortical layers. The depth gauge determines the length of the holes. Taking this into account, self-tapping screws of the required length with a diameter of 2 mm are selected. The device is fixed to the bone fragments with 6 screws so that the latter pass through 2 cortical layers. The screws are tightened until they stop. The device screw is brought out through a separate incision

(0.3 mm) on the skin in the area behind the ear. In a similar way, the second KDA is fixed in the area of ​​the angle of the lower jaw on the other side. Using an oscillating saw, an extended osteotomy of the mental region is performed: after the mental region, the osteotomy line goes through the body to the angle of the lower jaw on both sides. The osteotomy line passes below the roots and buds of the teeth. Compression of the bone fragments is performed (Fig. 2). Hemostasis is carried out during the operation. The wound is sutured. A suture is placed on the wound in the area where the screw of the device comes out on the skin.

Rice. 2. Schemes of the developed method: a - operation; b - the result obtained.

In the postoperative period, antibacterial therapy, rinsing the mouth with an antiseptic solution, and daily change of aseptic dressings are carried out.

Distraction begins on the 5th day after surgery, 0.5 mm per day in 2 doses of 0.25 mm. The retention period lasts at least 12 weeks.

Method for simultaneous elimination of underdevelopment of the branch and body of the lower jaw

Patients are prepared for planned surgery according to general rules: general blood test with hemosyndrome, blood group and Rh factor, biochemical blood test, general urinalysis, electrocardiogram. The main stages of the preoperative examination: X-ray (teleradiograms in two projections, orthopantomogram, computed tomography), cephalometry, photo documentation.

The operation is performed under endotracheal anesthesia. The lower jaw is skeletonized using an incision of up to 6 cm in the submandibular region on the affected side. An osteotomy line is marked in the area of ​​the branch and body: the outer cortical layer is sawed with a bur or saw, and along the anterior and posterior edges of the lower branch

the jaws saw through the outer and inner cortical plates (the inner cortical plate in the middle part is preserved). The bone-mounted CDAs are installed, previously untwisted by 2 - 3 mm, so that compression can be carried out subsequently. Apparatus in the region of the mandibular ramus

installed parallel to its posterior edge, and on the body - parallel to the occlusal plane; in addition, the screw of the device is brought out through a separate incision (0.3 mm) on the skin in the area behind the ear. Using a drill with a diameter of 1.6 mm, create holes for the screws. Holes are drilled through 2 cortical layers. The depth gauge determines the length of the holes. Taking this into account, self-tapping screws of the required length with a diameter of 2 mm are selected. The devices are fixed to the bone fragments so that the screws

pass through 2 cortical layers. The screws are tightened until they stop. An osteotome is used to break the inner cortical plate. Compression of bone fragments is performed. Hemostasis is carried out during the operation. The wound is sutured layer by layer (Fig. 3).

Rice. 3. Scheme of the developed method: a - operation; b - the result obtained.

Antibacterial therapy and daily change of aseptic dressings are carried out in the postoperative period.

Distraction begins on the 5th day after surgery, 1 mm per day in 4 doses of 0.25 mm. The retention period is at least 12 weeks.

Elimination of underdevelopment of the middle zone of the face

Preparing patients for a planned operation is carried out according to general rules: complete blood count with hemosyndrome, blood group and Rh factor, biochemical blood test, general analysis

urine, electrocardiogram. The main stages of the preoperative examination are x-ray (teleradiograms in two projections, orthopantomogram, computer tomography).

mography), cephalometry, photo documentation.

The operation is performed under endotracheal anesthesia. Before the operation, boys are shaved bald, and girls have their hair shaved in the form of a path about 4 cm wide along the intended incision. Bilateral transvenous access is used. The cut line is wavy. Before the incision, hydropreparation of the tissue is carried out. The frontal bone is skeletonized so that the periosteum remains 2 cm before the upper edge of the orbits. The temporal and infratemporal fossa are separated from the muscles on both sides. Skeletonizes the root of the nose and nasal bones. Very carefully, the roof and bottom of the orbits are isolated. When skeletonizing the medial walls of the orbits, the nasolacrimal canal is carefully isolated, and a ligature is also applied in the area of ​​the canthal ligaments in order to fix them in the right place when suturing the wound. WITH

using an oscillating saw, an osteotomy is performed along the line of the frontonasal suture, continuing the osteotomy line down through the bony part of the nasolacrimal canal (without damaging the soft tissue part

channel), the bottom of the orbit. Next, the cut is carried out upward, along the lateral edge of the orbit and ends at the level of the frontozygomatic suture. Also, using an oscillating saw, an osteotomy of the zygomatic arch is performed closer to the zygomatic bone in its widest part. Then, using 3 small incisions in the oral cavity along the transitional fold of the upper jaw, access is made to the vomer and pterygomaxillary joints. An osteotomy of the vomer is also performed in the area of ​​the pterygomaxillary joint on both sides. Using a curved chisel, an osteotomy is performed in the area of ​​the nasal root along the vertical plate of the ethmoid bone and the vomer. At this point, you must be extremely careful not to damage the endotracheal tube. Once all cuts have been made, the midfacial complex is mobilized using Rowe forceps.

The bone apparatus is fixed with self-tapping screws to the zygomatic and parietal bones. When fixing to the zygomatic bone, screws with a diameter of 2 mm and a length of 7 mm are used, and when fixing to the parietal bone, screws with a diameter of 2 mm and a length of 5 mm are used. After fixing the devices, compression is performed. It is important to note that the devices are installed parallel to the zygomatic arches. Careful hemostasis is carried out throughout the entire operation. The wound is sutured in layers.

In the postoperative period, antibacterial therapy, thorough oral hygiene and daily change of aseptic dressings are carried out.

Distraction begins on the 7th day after surgery, 1 mm per day in 4 doses of 0.25 mm. After the required functional and cosmetic result is achieved, the distraction is stopped. The duration of the retention period is on average 12 weeks.

Possible complications when using medical technology and ways to eliminate them

1. Lack of bone regenerate. Individual rhythm and tempo of distraction, repeated distraction.

2. Osteomyelitis or inflammation of soft tissue in the area of ​​the device, sinusitis. Compliance with the rules of asepsis and antisepsis, antibacterial therapy, early removal of the device.

3. Device breakdown. Replacing the device. Repeated distraction.

4. Incorrect vector of distraction and, as a consequence, a violation of facial aesthetics or a discrepancy between the functional result and the expected one. Repeated corrective surgery.

Effectiveness of the use of medical technology

The EDC method was used in 198 patients with underdevelopment and/or defects of various congenital and acquired skull bones aged from 14 days to 17 years. Of these, 156 children had underdevelopment and/or defects of the lower jaw of a congenital or acquired nature; with underdevelopment of the upper jaw after cheilouranoplasty for congenital unilateral cleft of the upper lip, alveolar process and palate - 16; with underdevelopment of the upper jaw after cheilouranoplasty for congenital bilateral cleft of the upper lip, alveolar process and palate - 12 children; with Binder syndrome - 2; with Crouzon syndrome - 10; with Apert syndrome - 1 child; with plagiocephaly - 1 patient. The operations were performed according to vital, functional and cosmetic indications.

As a result of applying the EDC method, the following results were obtained: good - in 77.3%, satisfactory - in 13.6% of patients and negative - in 9.1% of children (Fig. 4). With good and

In satisfactory results, the length of the bone regenerate was 10 - 40 mm.

Rice. 4. Diagram of the obtained results.

During lengthening of the mandibular ramus without distraction of the upper jaw, an open bite is formed on the affected side from 7 to 12 mm.

After removal of the CDA, after 1 month, the open bite is not determined, which is not due to the growth of the upper jaw, as was previously thought, but to the reduction of the regenerate due to the action of the masticatory muscles. The size of the reduction is 40-50% of the original length. So, to avoid this type

complications, it is necessary to simultaneously lengthen the branch of the lower jaw with the upper jaw. The need for distraction of the upper jaw with congenital pathology is 75%, and with acquired pathology - 30%.

The proposed method for simultaneous elimination of underdevelopment of the lower and upper jaws has the following advantages:

— the age limit has been significantly reduced, the method can be used from 1.5 years;

— there is no intermaxillary fixation;

— the function of the upper and lower jaws is preserved, which has a positive effect on the formation of the regenerate;

— the possibility of nutritious nutrition and adequate oral care;

— acceptable appearance of the patient;

— there are no postoperative scars on the skin;

— unlimited retention period;

— the risk of developing inflammatory processes is significantly reduced;

— the possibility of performing independent distraction of the upper and lower jaws with an individual distraction schedule for each jaw.

In children with bilateral underdevelopment and/or a defect of the lower jaw, congenital or acquired, underdevelopment of the chin is always determined, especially for patients with Treacher-Collins syndrome and patients who have long suffered from bilateral ankylosing lesions of the temporomandibular joint. After eliminating bilateral underdevelopment or defect of the lower jaw and restoring a constructive bite, about 70% of children require surgical correction of the chin.

Numerous methods of genioplasty are known using autografts, allografts, and plastic surgery using endoprostheses made of various synthetic materials (EGMASS-12, silicone, PolyGap).

The method for eliminating underdevelopment of the chin of the lower jaw has the following advantages:

— the age limit has been significantly reduced, the method can be used from 5-6 years;

— absence of possible negative aspects characteristic of methods using different types of transplants;

— absence of foreign material;

— genioplasty is performed exclusively with local tissues;

— predictable result, the possibility of changing the position of the chin fragment of the lower jaw depending on the wishes of the patient and parents during the distraction process.

Children with congenital and acquired pathology of the lower jaw in 80% of cases need to eliminate underdevelopment and/or defects not only of the branch, but also of the body of the lower jaw. Existing two-stage methods significantly increase treatment time.

Advantages of the method of simultaneous elimination of underdevelopment of the branch and body of the lower jaw:

— acceptable appearance of the patient;

— there are no additional postoperative scars on the skin from the rods;

— unlimited retention period;

— the risk of developing inflammatory processes is significantly reduced;

— easier care of the KDA.

Bony KDA for the midface has the following advantages:

— ensuring rigid fixation of bone fragments during periods of distraction and retention, which is one of the main conditions for the maturation of bone regenerate;

— the ability to perform compression of bone fragments after their osteotomy, which is the main prevention of postoperative bleeding;

— strictly dosed movement, i.e. the size of the regenerate always corresponded to the duration of distraction, for example, with distraction for 20 days at 1 mm per day, the length of the regenerate was 20 mm;

— device weight 5 g;

— acceptable appearance of the patient;

- normal oral hygiene;

— simple care of the distraction apparatus during distraction and retention;

— the retention period is not limited;

— the possibility of using CDA in early childhood;

— it is possible to change the position of the middle zone of the face depending on the wishes of the patient and parents during the process of distraction.

Thus, the use of CDO currently makes it possible to significantly increase the effectiveness of treatment of children with complex maxillofacial pathologies of a congenital and acquired nature, and also makes it possible to provide real medical care to children with deformities and defects of the facial skull using a gentle method.

The CDO method is a priority in pediatric practice, and its further development and implementation allows us to consider it the main one in the treatment of children with defects and deformities of the maxillofacial and craniofacial areas.

Widespread implementation of the distraction method will significantly increase the efficiency and effectiveness of reconstructive surgical interventions, reduce the time of rehabilitation and patients’ stay in a hospital bed. To a large extent, there will be no need to use endoprostheses and highly traumatic methods for eliminating defects. There is no need to solve complex problems of eliminating secondary deformities in adult patients, since children will enter “adult” life having undergone comprehensive rehabilitation.

Authors:

prof. V.V. Roginsky

Doctor of Medical Sciences D.Yu. Komelyagin

Candidate of Medical Sciences S.A. Dubin

Osteosynthesis methods

There are direct and indirect methods of osteosynthesis.

Direct methods:

— intraosseous osteosynthesis using knitting needles, rods, pins and screws,

— bone osteosynthesis using bone plates, staples, circular ligatures, frames,

— intraosseous osteosynthesis based on bone sutures or their combination with knitting needles and staples.

Indirect osteosynthesis is based on the use of various fixation devices, both extraosseous (bone clamps and clamps) and intraosseous (rods, pins, screws and knitting needles).

Osteosynthesis can be performed both under local anesthesia in combination with neuroleptanalgesia and ataralanalgesia, and under general anesthesia.

The nature of the access (extraoral or intraoral) is determined by the doctor.

If osteosynthesis is performed using an extraoral approach, then in case of a fracture in the area of ​​the angle and body of the lower jaw, the doctor makes an incision in the submandibular region. If the fracture occurred in the frontal area, the incision will be in the submental area. For fractures in the area of ​​the condylar process - in the retromandibular region. During the operation, the doctor exposes bone fragments, removes small fragments, and fixes large fragments and fragments in a normal anatomical position using the selected design.

If the doctor uses intraoral access to perform osteosynthesis, he makes an incision in the mucosa along with the periosteum, then compares the fragments and performs osteosynthesis.

Open focal osteosynthesis

Bone suture

Indications for application : fresh fractures of the upper jaw and lower jaw, zygomatic bone and arch, fractures with easily reducible fragments. Contraindications: the presence of a developed inflammatory process in the fracture site (inflammatory infiltrate, abscess, phlegmon), traumatic osteomyelitis, gunshot injuries to the jaws, finely splintered and oblique fractures of the jaws, fractures with a bone defect. Material : for bone suture, stainless steel wire of grades 1Х18Н9Т, EP-400, EYAT-1, titanium, tantalum or nylon thread with a diameter of 0.6-0.8 mm is used. To apply a bone suture, the skin is cut and the ends of the fragments from the vestibular and lingual surfaces are exposed, they are compared and secured with a wire ligature passed through drilled holes in the bone.

Immobilization of fragments of the lower jaw: a — radiograph of the lower jaw on the right, lateral projection (the fragments are fixed with a bone suture); b — options for immobilization of fragments of the lower jaw using a bone suture (diagram)

Bone sutures are removed if inflammation develops in the fracture area (traumatic osteomyelitis) or a ligature fistula forms. The advantages of a bone suture are that the chewing function is preserved, normal oral hygiene is possible, and pathological conditions do not occur in the area of ​​the condylar process.

Mini bone metal plates

Indications for application : any fractures of the jaws, with the exception of finely fragmented ones. The advantage of mini-plates over a bone suture is that during the operation the periosteum is peeled off from only one (vestibular) surface of the jaw, which significantly reduces the disruption of microcirculation in the fracture area. To immobilize jaw fragments, mini-plates of various shapes and sizes are used. They are made of titanium or stainless steel. The length of mini-plates can range from 2 to 24 cm, thickness - from 1 to 1.4 mm. Screws for fastening miniplates have a diameter of 2.0 and 2.3 mm and a length from 5 to 19 mm. To apply mini-plates, the skin is incised and the ends of the fragments are exposed 2.0-2.5 cm from the fracture gap on the vestibular surface, they are compared and secured with a plate, which is screwed in with screws.

X-ray of the lower jaw on the right, lateral projection. Fragments are fixed with metal mini-plates

Currently, miniplates are applied using an intraoral approach without cutting the skin.

Fast-hardening plastics (E.Sh. Magarill)

Indications: fractures in the area of ​​the body of the lower jaw. Contraindications: fracture of the condylar process, comminuted fractures. Application technique: the fragments of the lower jaw are exposed from the outer surface and juxtaposed into the correct position. On their vestibular surface, a groove 0.5 cm wide is drilled for 1.5 cm on both sides of the fracture gap to the depth of the cortical plate. The shape of the gutter resembles an inverse cone. Rubber-like plastic is packed into the chute. After hardening, its excess is removed with a milling cutter. The wound is sutured.

Osteoplast glue (G.V. Golovin, P.P. Novozhilov)

Osteoplast adhesive is a modified resorcinol epoxy resin with organic fillers with a curing time at room temperature of 5-10 minutes. After applying the glue, the fragments must be kept motionless for 10-15 minutes until it hardens, after which the wound is sutured.

Metal staples with predetermined properties (V.K. Polenichkin)

The staples are made of nickel-titanium wire (50.8 at% and 49.2 at%) with a diameter of 1.6 mm. This alloy becomes soft and easily deformed when significantly cooled, but regains its original shape and rigidity at room temperature. Staples have different shapes and are used depending on the type and location of the fracture. They are applied to the exposed ends of fragments of the lower jaw. Through channels are drilled into them, at a distance of 1.0-1.5 cm from the fracture gap; the distance between the channel holes should be greater than the distance between the “legs of the staple.” The staple is cooled with chloroethyl, stretched and its ends are inserted into the drilled channels of the previously reduced fragments. After warming, the staple restores its original shape, and its ends create compression and immobilization of the fragments.

Immobilization of mandibular fragments using metal staples with predetermined properties

Kirchner spokes

Indications : fracture of the body of the lower jaw in the lateral region with fragments that are difficult to reduce and the inability to reduce them by hand, interposition of soft tissues, fracture of the condylar process with displacement of fragments, fractures in the chin in combination with a wire ligature. To apply the wires, the fragments are exposed and reduced. Next, the needle is passed from one fragment to another at least 3 cm in each. The wire is shortened with pliers, leaving ends protruding from the bone 4-5 mm long. After consolidation, the wire is removed.

Combination of bone suture and wire

Used for stronger and more reliable fixation of fragments of the lower jaw.

Osteosynthesis of fragments of the upper jaw using a bone suture (a, b) and a wire (c)

Bone or wire suture

In 1825, surgeon Rogers from Dublin performed the world's first operation using silver wire. With its help, he connected the fragments of the lower jaw. Later, in 1863, Russian surgeon Yu.K. Szymanowski successfully used a bone suture. From this point on, the bone suture was successfully used for osteosynthesis for many years. The main material was initially stainless steel, later it was replaced by titanium, nichrome, tantalum, etc.

There are various modifications of the bone suture (loop-shaped, cruciform, figure-of-eight, trapezoidal, double, etc.). The choice depends on the nature and location of the fracture.

The application of a bone suture occurs according to certain rules. It is important to make holes for the material in those areas where damage to the mandibular canal and tooth roots is excluded, and no closer than 1.0 cm from the fracture line. Ideally, the suture should cross the fracture line in the middle of the distance between the edge of the mandible and the base of the alveolar process.

Metal Kirschner spokes

This type of wire was first used to treat fractures of the lower jaw in 1933. Intraosseous insertion of these wires can be carried out both percutaneously (without incisions) and with soft tissue incisions.

In 1975 V.V. Donskoy used an original technique, with which he inserted a wire into the branch of the lower jaw through the mucosa without an incision, then carried out a reposition, and fixed it like a splint to the teeth or to a splint. Later, in 1988, Deryabin E.I. and Osipov V.Yu., and Yu.G. Kononenko and G.P. Ruzin proposed modifications of this method in 1991. Today there are many techniques where the wire suture is combined with knitting needles, staples, surrounding wire ligatures, etc.

International standards

A real revolution in maxillofacial surgery occurred in 1958, when M. Muller, M. Allgower, R. Schneider, H. Willenegger organized the International Association for the Study of Internal Fixation (AO/ASIF - Ardeitsgemeinschaft fur Osteosynthesefragen/Association for the Study of Internal Fixation – working association for the study of osteosynthesis/association for the study of internal fixation).

According to the postulates of AO/ASIF, the osteosynthesis technique implies that:

1. the structures used must be made of bioinert metal alloys;

2. bone fragments must be anatomically accurately compared and fixed;

3. the use of gentle surgical techniques ensures the preservation of blood supply to bone fragments and surrounding soft tissues;

4. stable fixation of fragments is ensured by interfragmentary compression;

5. early application of functional load is indicated;

6. restoration of contractile activity of muscles and movement in the joint.

AO/ASIF staff also developed and implemented metal plate systems for mandibular osteosynthesis:

· dynamic compression plates;

· reconstructive (blocking) plates (Locking reconstruction plates);

· blocking (locking) plates (Locking plates 2.0 mm);

· universal plates (Universal fracture plates);

· mandibular plates (Mandible (Mandible plates 2.0 mm).

They developed dynamic compression plates (DCP), through which it was possible to create compression between fragments for their primary fusion. The design of these plates includes oval holes with beveled walls, which allows the fragments to be brought closer together when the screws are tightened. The use of dynamic compression plates made it possible to achieve stable internal immobilization, reduced the number of cases of delayed fusion of fragments, and eliminated the need for additional fixation. But their use still does not eliminate the risk of microcracks in the area of ​​the fracture line and the development of osteoporosis in the bone at the site of contact with the plate.

The locking plate/screw system, with threaded plate holes and locking screw heads, was developed to prevent bone necrosis under the plate. The system provides rigid fixation of bone fragments using a plate and a plate and screws to each other - this helps prevent the screws from unscrewing and avoid possible displacement of the fragments while tightening the screws in the hole of the plate. The plate itself is located at a certain distance from the surface of the bone, which prevents the development of lysis.

Foreign studies have not revealed significant differences in the effectiveness and possible development of postoperative complications during osteosynthesis with locking plates with screws and non-locking plates.

Another system developed by AO/ASIF experts is the LCP (locking compression plate system with angular stability) is a design of multi-cell plates with numerous holes and consists of two parts: a threaded one for fixing the head of a locking screw and a hole for creating dynamic compression by eccentric insertion of standard cortical or cancellous screws.

Installation of the plate requires special tools and is carried out according to clearly established technology.

If the adjustment of the LCP to the shape and relief of the outer surface of the lower jaw bone is carried out in accordance with the established requirements, then this creates ideal conditions for the fusion of fragments during osteosynthesis of multiple comminuted fractures of the lower jaw of various locations, in case of suppuration of a bone wound, traumatic osteomyelitis, in case of a fracture with the occurrence of a bone defect tissue, fracture of toothless jaws. Limited contact of LCP with bone helps prevent the development of bone necrosis under the plate.

Osteosynthesis of the upper jaw

In their practice, maxillofacial surgeons often have to deal with this type of injury such as a fracture of the upper jaw. Most often, it is received by participants in road accidents or conflict situations involving the use of physical force, as well as fans of extreme sports. A fracture of the upper jaw is an incredibly dangerous type of injury, since it directly damages the skeleton of the victim’s face, and this threatens not only the appearance of noticeable aesthetic defects, but also a very high risk of developing a number of serious complications. For example, displacement of bone fragments and/or severe swelling, which inevitably occurs during a fracture, can lead to the closure of the upper respiratory tract, resulting in a person developing suffocation. In addition, bone fragments of the jaw can damage large blood vessels, as well as nerves of the head and neck. Therefore, it is very important to understand that a fracture of the upper jaw is an extremely serious injury, and failure to promptly seek medical help can lead to irreversible consequences, including death.

A fracture of the upper jaw is accompanied by very severe pain, swelling in the area of ​​tissue damage and disruption of facial symmetry; Also, curvature of the upper dentition may be noticeable. If there are any signs of a fracture of the jaw bone, you should immediately seek help from a specialist, because with each missed day, the chances of restoring the primary shape of the facial skeleton become less and less.

Before starting treatment for a fracture, the doctor conducts the necessary examination of the patient, during which the patient undergoes an X-ray or computed tomography, after which, depending on the nuances of the existing injury, he determines the most appropriate method of surgical treatment of a jaw fracture - osteosynthesis.

Surgical treatment of a fracture of the upper jaw is always performed under anesthesia, so the patient does not experience absolutely any discomfort during the procedure. Having thoroughly disinfected the patient's operated area, the doctor makes a small incision in the soft tissues of the oral cavity and performs direct manipulations on the bone fragments - using special metal knitting needles or titanium plates, the surgeon connects the bone fragments, securely fixing them in the correct position. In some cases of fracture, osteosynthesis of the upper jaw can be carried out without dissecting soft tissues - this method is used for undisplaced fractures. The choice of a specific technique for osteosynthesis of the upper jaw is determined by the maxillofacial surgeon on an individual basis, based on the complexity of the bone tissue damage and the presence of any complications. However, in any case, the doctor chooses a method of surgical treatment of a jaw fracture in which he would be able to restore the anatomically correct structure of the jaw bone and preserve the aesthetic appearance of the patient’s face.

After osteosynthesis of the upper jaw, the bone fixed in the correct position quickly grows together. If the patient had fixation structures installed on the jawbone, then after complete restoration of the hard and soft tissues, the patient’s face looks exactly the same as before the fracture.

At the Medistar clinic, osteosynthesis of the upper jaw is carried out using the latest techniques using cutting-edge materials. When treating fractures of the facial bones, our doctors strive not only to correctly restore the damaged tissue, but also to preserve the beauty of the victim’s face as much as possible. And by taking into account the individual characteristics of each patient’s body when drawing up a course of treatment, our doctors are able to shorten the period of postoperative recovery and prevent the development of any undesirable consequences in the future.

3228 zn

Recommendations

Treatment of mandibular fractures involves long-term immobilization of the jaws, which becomes a significant psychological problem for the patient. The success of treatment directly depends on how closely both the doctor and the patient act together and take the process seriously.

For the entire period of healing of the fracture, the patient is prescribed a diet (maxillary table No. 1 and No. 2); food is allowed to be taken only in a creamy consistency (well boiled and passed through a blender). In most cases, opening the mouth is impossible, because... The patient has an intermaxillary rubber traction device installed. Food is supplied through tubes, tubes and sippy cups.

From the moment of double-jaw splinting or osteosynthesis, the splints are left in place for an average of 21–30 days. If the doctor has confidence in the favorable course of the recovery process, then it is possible to reduce the period of wearing the intermaxillary rubber traction.

Even after removing the splints, the patient cannot fully open his mouth for 1-2 weeks. To restore the function of the chewing and facial muscles, he is prescribed myogymnastics.

Comparative assessment of the effectiveness of three methods of gentle immobilization of the lower jaw for fractures

G. A. Khatskevich Doctor of Medical Sciences, Professor, Head of the Department of Pediatric Dentistry with a course of Maxillofacial Surgery at St. Petersburg State Medical University named after. acad. I. P. Pavlova (St. Petersburg)

V. G. Avetikyan Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Dentistry with a course of Maxillofacial Surgery at St. Petersburg State Medical University named after. acad. I. P. Pavlova (St. Petersburg)

I. G. Trofimov Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Dentistry with a course of Maxillofacial Surgery at St. Petersburg State Medical University named after. acad. I. P. Pavlova (St. Petersburg)

Zhang Fan , doctor, postgraduate student at the Department of Pediatric Dentistry with a course in Maxillofacial Surgery at St. Petersburg State Medical University named after. acad. I. P. Pavlova (St. Petersburg)

I. Yuan Ph.D., Lecturer at Shanghai University (Shanghai, China)

V. B. Nekrasova Doctor of Medical Sciences, Professor of St. Petersburg MAPO (St. Petersburg)

Patients with injuries of the maxillofacial area make up about 30% of all patients treated in hospitals for maxillofacial surgery, while fractures of the lower jaw make up about 70-85% of all fractures of the facial bones (Ivasenko P.I., Zhurko E. P., Chekin A.V., Konvay V.D. et al., 2007; Inkarbekov Zh.B., 2009; Bakardjiev A., Pechalova P., 2007).

An analysis of data published in the scientific literature showed that the frequency of complications of mandibular fractures reaches from 10 to 41% (Mubarkova L.N., 2008; Mirsaeva F.Z., Izosimov A.A., 2009), which does not allow us to talk about effectiveness existing treatment methods.

An important pathogenetic link in the development of inflammatory complications in fractures of the lower jaw is a violation of local immune defense, regional blood circulation and innervation in the fracture zone, deterioration of oral hygiene and impaired chewing function (Timofeev A. A., 2004; Berkhman M. V., Borisova I. V., 2007; Magomedgazhiev B. G., 2008; Inkarbekov Zh. B., 2009). Moreover, these changes can be provoked not only by the injury itself, but also by inadequate fixation methods. This especially applies to round aluminum or tape dental splints. Their application is extremely traumatic for the patient and dangerous for the surgeon due to the possibility of hand injury and infection.

In addition, dental splints, used for an average of 30 days, complicate oral hygiene and injure the periodontal border. This leads to the development of pronounced inflammatory changes in the periodontium. Fractures of the lower jaw occur quite often, in which there is no displacement of the fragments and mobility is low. In this case, the immobilization provided by dental splints turns out to be redundant. In this regard, the development of gentle immobilization methods is of particular relevance.

Material and research methods

The work is based on the experience of treating 90 patients with fractures of the lower jaw. Of these, in 48 patients, the method of gentle immobilization—intermaxillary fixation using fixed orthodontic equipment—was used as the main and auxiliary (during osteosynthesis surgery) method of fixation (Fig. 1).

Rice. 1a. The stage of gluing Protekt dental buttons-braces. Immobilization of the lower jaw using elastic rings (the least traumatic method).

Rice. 1b. The stage of gluing Protekt dental buttons-braces. Immobilization of the lower jaw using elastic rings (the least traumatic method).

The comparison methods used were: immobilization of fragments with wrapping transmaxillary sutures - 18 patients (Fig. 2).

Rice. 2a. Immobilization of the lower jaw using two wire wrapped sutures.

Rice. 2b. Immobilization of the lower jaw using two wire wrapped sutures.

Intermaxillary suspension using orthodontic mini-implants - 24 patients (Fig. 3).

Rice. 3. Immobilization of the lower jaw using intraosseous implants of fixators and elastic rings.

The control group included 16 males (22.9 ± 1.2 years), practically healthy.

In the main group of patients, where Protekt braces and lingual buttons were used, biologically active additives (dietary supplements) "Lesmin" for oral administration and individual oral hygiene using dental Fitolon pastes.

For diagnosis and evaluation of results, clinical and radiological immunological, index-hygienic methods, electromyography and Doppler flowmetry were used to assess vascular microcirculation.

Indications for choosing the immobilization method using fixed orthodontic equipment (Protect) are as follows. The independent method of immobilization of the lower jaw, as an alternative to splinting, was used in the following cases: unilateral fractures without displacement or with slight displacement; bilateral fractures without displacement or with slight displacement; fracture of the condylar process without clinically detectable and functionally significant displacement (slight limitation of movements in the temporomandibular joint due to pain, the bite is not disturbed). In case of bilateral fractures of the lower jaw, in a number of cases where osteosynthesis was performed with titanium plates, bracket fixation was used as an additional method (Fig. 4).

Rice. 4. Bilateral fracture of the lower jaw. Immobilization was carried out using osteosynthesis and braces.

The analysis included only those cases where the method of gentle immobilization was used as the main method of fixation of fragments and the patients fully followed the recommendations for oral hygiene proposed by the authors. A total of 66 clinical cases were analyzed. Variants of fractures in percentage and their ratio are presented in Figure 5.

Rice. 5. Variants of mandibular fractures with gentle immobilization methods.

Research results

Patients of all 3 groups were observed from the start of treatment and for 3 months. The final assessment of treatment results was carried out 3 months after injury. Inflammatory complications were taken into account throughout the treatment. Consolidation of fragments occurred in all patients, regardless of the method of gentle immobilization. Malocclusion was detected in only one patient, whose jaw was immobilized using orthodontic mini-implants. In this case, it was possible to restore the bite by selective grinding of the teeth. The effectiveness of treatment with the methods under consideration was the same.

Inflammatory complications were observed with all methods of gentle immobilization, while in the case of using fixed orthodontic equipment (group 1), only one patient (4.2%) had a limited osteomyelitic process due to a tooth fracture left in the gap with pulp necrosis versus 12. 6% when fixed with mini-implants and 16.6% when fixed with wrapping transmaxillary sutures (Fig. 6).

Rice. 6. Frequency (%) of inflammatory complications with different methods of gentle immobilization.

In the second group (using mini-implants), 1 patient had a hematoma suppuration, and 2 patients had a limited osteomyelitic process. In the third group (wrapping transmaxillary sutures), 2 patients had suppuration of postoperative hematomas in the tissues of the floor of the mouth and one patient had chronic traumatic osteomyelitis. Thus, in the group of patients in whom gentle immobilization was performed using fixed orthodontic equipment, the number of inflammatory complications is minimal, which is due not only to less additional trauma during the procedure for immobilizing fragments, but also to the systemic use of dietary supplements.

Questionnaires to study self-assessment of quality of life were filled out by patients 1 month after the injury when the fixation structures were removed. A comparative analysis of the study results was carried out in samples of 12 patients from each group. A study of the “quality of life” profiles in patients using different methods of gentle immobilization showed that the quality of life decreases to a lesser extent in patients with fractures of the lower jaw when fixed using fixed orthodontic equipment and mini-implants (Fig. 7).

Rice. 7a. Comparative assessment of relatively healthy respondents’ QoL profiles with different methods of gentle immobilization. OTMS - wrapping transmaxillary sutures.

Rice. 7b. Comparative assessment of relatively healthy respondents’ QoL profiles with different methods of gentle immobilization. OMI - orthodontic mini-implants.

Rice. 7th century Comparative assessment of relatively healthy respondents’ QoL profiles with different methods of gentle immobilization. NOT - fixed orthodontic technique.

One month after the injury, self-assessment of the quality of life in patients with fractures of the lower jaw with a gentle method of immobilization using fixed orthodontic equipment on all scales of the physical component of health and one scale of the mental component (vitality) was higher than in patients with fixation using wrapping transmaxillary sutures.

When determining the level of oral hygiene, the Fedorov-Volodkina Hygiene Index (FHI) and the severity of periodontal inflammation according to the papillary-marginal-alveolar index (PMA) were recorded; at the initial examination, no statistically significant differences were found in patients of the three groups.

The highest RMA values ​​were found in the group of patients where fixation of fragments was carried out using wrapping transmaxillary sutures - 43.3 ± 2.4%

Subsequently, when examined after 7 days, the level of oral hygiene worsened regardless of the method of gentle immobilization and was assessed in all groups as unsatisfactory. When examined a month later, a further increase in IGPV was observed in all groups, however, in the group using fixed orthodontic technology, the increase in IGPV was found to a lesser extent - 2.4 ± 0.03 versus 2.64 ± 0.07 points (p < 0.01) in the group where fixation was carried out using orthodontic mini-implants.

Compared to the initial values, an increase in inflammation during treatment was observed in all groups of patients. At the same time, the highest RMA values ​​were established in the final study in the group of patients where the fixation of fragments was carried out using wrapping transmaxillary sutures - 43.3 ± 2.4%, and the lowest with the gentle method of immobilization we proposed using fixed orthodontic equipment - 26.4 ± 0.8% (Table No. 1).

Table No. 1. Comparative analysis of the dynamics of dental indices with gentle methods of immobilization of the lower jaw, used as the main ones.

Note: the differences relative to the initial examination are statistically significant: * - p<0.05; ** — p<0.01; *** — p<0.001; 1st time during the initial examination; 2nd time after 7 days (at discharge); 3rd time after 1 month. (when removing structures).

This result is associated with the use of surgical intervention in the comparison groups that stimulates the inflammatory response. Less severe inflammation in the final study could have been influenced by the use of the Lesmin dietary supplement by patients in the experimental group and the use of Fitolon toothpaste.

The study of factors of nonspecific protection and local immunity in the oral fluid of victims with fractures of the lower jaw during the initial examination revealed that in all groups there was a significant decrease in lysozyme activity compared to healthy individuals against the background of activation of mucosal immunity (increased levels of immunoglobulins) with a pronounced imbalance of pro- and anti-inflammatory cytokines (increased IL-8 and decreased IL-4). When examined a week later, a decrease in lysozyme activity relative to the initial data was found only in patients with entwined transmaxillary sutures (65.5 ± 2.1 versus 73.1 ± 2.3% at p < 0.01). In the same group, the lowest levels of lysozyme activity were found after a month (63.6 ± 2.2%), although upon admission in this group the activity of lysozyme was the highest (Fig. 8).

Rice. 8a. Dynamics of lysozyme and sIgA activity in patient groups. Note: NOT - 1st group, OMI - 2nd group, OTMS - 3rd group.

Rice. 8b. Dynamics of lysozyme and sIgA activity in patient groups. Note: NOT - 1st group, OMI - 2nd group, OTMS - 3rd group.

When examined after 7 days, in groups 1 and 2 the level of sIgA decreased slightly, and in group 3 it increased just as slightly. The final examination a month later showed a slight decrease (normalization) of sIgA in group 1, where we used the gentle immobilization method we proposed using fixed orthodontic equipment - 56.1 ± 3.8 versus 72.5 ± 5.78 μg/mg of protein ( p < 0.01) and 77.7 ± 11.4 μg/mg protein.

Studies have shown that when using fixed orthodontic equipment as the main method of fixation, inflammatory complications in the fracture zone are detected in 4.2% of cases

When examined after 7 days, IgG was still at high levels in all groups. Against this background, only in the experimental group of patients was there a decrease in IgM to the control level (from 2.3 ± 0.2 to 1.37 ± 0.1 μg/mg protein, with p < 0.001). A month later, a study confirmed the normalization of IgM levels only in the experimental group, where we used the gentle immobilization method we proposed using fixed orthodontic equipment (1.38 ± 0.1 versus 1.9 ± 0.13 and 2.49 ± 0.26 μg/ mg protein in comparison groups). Moreover, after a month in the experimental group, IgG decreased most significantly (3.77 ± 0.3 versus 4.6 ± 0.45 and 5.0 ± 0.4 μg/mg of protein in the comparison groups).

During the initial examination, the level of IL-8 was 9 times higher than that of the control group; in some patients it was more than 5000 pg/ml, and in some cases IL-4 was not detected at all. Against the background of such large-scale changes in the regulators of the immune response, the smallest were found in patients in the experimental group. Thus, after 7 days they showed a decrease in IL-8 (from 2707.9 ± 198.7 to 1916.3 ± 199.0 pg/ml, with p < 0.01), and when examined a month later, it was in this group has the lowest level of IL-8 (1488.2 ± 183.3 versus 1953.3 ± 202.1 and 2247.1 ± 304 pg/ml in the comparison groups) (Fig. 9).

Rice. 9. Dynamics of IL-8. Note: NOT - 1st group, OMI - 2nd group, OTMS - 3rd group.

The dynamics of IL-4 are less pronounced. In the experimental group, its amount practically does not change during treatment, remaining 2 times lower than in the control group, and in the comparison groups it further decreases. After a month, in patients of group 1, the level of IL-4 was 2.7 ± 0.2 versus 1.12 ± 0.4 and 1.0 ± 0.5 pg/ml in the comparison groups.

Thus, the study of the activity of lysozyme, mucosal immunity and the level of cytokines in the oral fluid showed that in response to a fracture of the lower jaw, the body responds with an acute-phase inflammation reaction, accompanied by a decrease in lysozyme activity against the background of activation of mucosal immunity and a pronounced imbalance of pro- and anti-inflammatory cytokines. When using the method of gentle immobilization developed by us against the background of systemic administration of the Lesmin dietary supplement, the normalization of disorders proceeds faster (in some cases, improvement occurs after 7 days), and when examined a month later, it is more pronounced, which is due to the less traumatic method of fixation and systemic administration of the biomodulator Dietary supplement "Lesmin"

conclusions

1. As a support for mandibulo-maxillary fixation, it is proposed to use non-removable orthodontic equipment: dental braces and lingual buttons, which will eliminate surgical intervention, which complicates the course of the restoration process in periodontal tissues, and will simplify and increase the effectiveness of treatment for patients with mandibular fractures.
2. When using fixed orthodontic equipment as the main method of fixation, inflammatory complications in the fracture zone were detected in 4.2% of cases. When using Fitolon toothpaste and Lesmin dietary supplement, better results were registered in comparison with the control. IGFV 2.4 + 0.03 versus 2.65 + 0.1 points at P < 0.05, and a decrease in the intensity of periodontal inflammation RMA 26.4 + 0.1 versus 36.8 + 2.0% at P < 0.001 .
3. Our data confirm the regulatory effect of cytokines in the development of inflammation. The initial increase in IL-8, as a consequence of injury, is physiologically determined and stimulates the mucosal immune system, without having a negative effect on such a factor of nonspecific defense of the oral cavity as lysozyme. However, high values ​​of IL-8 after a month negatively affect the restoration of lysozyme activity. At the same time, a decrease in the level of the anti-inflammatory cytokine IL-4, established at all stages of the study, is accompanied by an increase in lysozyme activity.
4. Restoration of lysozyme activity against the background of a decrease in elevated immunoglobulins in the oral fluid and a decrease in the degree of imbalance between pro- and anti-inflammatory cytokines leads to a decrease in the inflammatory reaction in the periodontium and an improvement in the hygienic state of the oral cavity, which confirms the effectiveness of the use of Fitolon toothpaste and the systemic use of the Lesmin dietary supplement. in patients with fractures of the lower jaw against the background of a gentle immobilization method using fixed orthodontic equipment.
5. A comparative analysis in three groups of patients with gentle immobilization showed that in the case of using fixed orthodontic equipment, the number of inflammatory complications is minimal, which is apparently due not only to less additional trauma during the procedure for immobilizing fragments, but also to the systemic use of dietary supplements. Moreover, a month after the start of treatment, these patients’ self-assessment of quality of life is higher than with other methods of gentle immobilization.
6. With the gentle immobilization method we developed, the normalization of identified violations of local nonspecific and immune defense proceeds faster - in some cases, improvement in indicators occurs within 7 days (decrease in sIgA, IgM and IL-8), and when examined a month later, the normalization is more pronounced (decrease in sIgA, IgM and IL-8 with an increase in lysozyme activity), which is due to both a less traumatic fixation technique and systemic administration of the biomodulator dietary supplement "Lesmin", which increases nonspecific resistance of the oral cavity and has an antioxidant effect.