Method for immobilizing fragments in case of mandibulo-maxillary fractures

FIELD: medicine, surgical stomatology.

SUBSTANCE: one should apply, at least, two symmetrical sutures performed with wire ligatures in position of central occlusion which embrace patient's mandibula and pass in openings located in maxillary alveolar process. Then one should apply a mental-parietal bandage. In peculiar case, one should install protective tubes in the openings in alveolar process to apply wire ligatures. The innovation enables to decrease the number of metal constructions in oral cavity and decrease parodontium trauma.

EFFECT: higher efficiency.

1 cl, 2 dwg, 4 ex

 

The invention relates to medicine, namely to oral surgery, and can be used for immobilization of bone fragments in fractures of the upper and lower jaws.

The known method of immobilization of bone fragments in fractures of the jaws, whereby carry out the reposition of bone fragments and fix the bite in the position of Central occlusion using wire nazebnych tire imposed on the upper and lower jaw (M.b.shvyrkov, Was, Vosstrebovan. Pellet fractures of the jaw: a Guide. - M.: Medicine, 1999. - 336 S.). Fractures of the lower jaw bite is fixed in the position of Central occlusion, connecting opposite hooks tires on the upper and lower jaws rigid or elastic thrust. Fractures of the upper jaw do the hanging jaw to the bones of the skull.

The main disadvantage of this method is the fact that the imposition and carrying nazebnych tire wire structure damage the periodontal teeth. Massive wire designs cause patient discomfort and significantly reduce the level of oral hygiene. In addition, the imposition wire bus is not always possible in severe secondary adentia or complete absence of teeth.

The objective of the invention is to provide a method of immobilization of bone fragments in fractures of the jaws, allowing izbezhat the trauma of periodontal teeth and reduce the amount of metal structures in the mouth.

The problem is solved in that in the method of immobilization of bone fragments in fractures of the jaws, including the reposition of bone fragments and fixation of the bite in the position of Central occlusion, according to the invention, for fixing the bite in the position of Central occlusion impose at least two symmetrical seam made with a wire ligatures, which cover the lower jaw and held in the holes formed in the alveolar bone of the upper jaw.

To prevent the eruption of the bone tissue into the holes in the alveolar ridge install a protective tube, through which the conducting wire ligatures.

The imposition of at least two symmetrical seams, made of wire ligatures, which cover the lower jaw and held in the holes formed in the alveolar bone of the upper jaw, firmly secures the bite in the position of Central occlusion. No need to overlay nazebnych wire tire avoids injury to the periodontal teeth. This reduces the number of metal structures in the oral cavity, increasing the level of oral hygiene. The execution of the method is possible in severe secondary adentia or complete absence of teeth. The method is simple and requires significantly less time to implement.

Figure 1 shows the schema issue the log method in fractures of the lower jaw; figure 2 - fractures of the upper jaw.

The method is carried out, for example, as follows.

As a material for joints using a titanium wire with diameter of 0.5 mm without coating, past dry-heat sterilization. For holding the wire bead around the lower jaw used surgical needle is large in size. Holes in the upper jaw execute drill with a diameter of 1.7 mm titanium wire wear fragments subclavian catheters No. 3, which move into the drilled bone hole to prevent the eruption of the bone wire.

Fractures of the mandible (Fig 1) the intervention is performed under infiltration anesthesia on upper and lower jaw with 2% lidocaine solution. Usually there was enough of 15-20 ml of the drug. After performing anesthesia through punctures of the skin in the submandibular areas on two sides of the vestibular and lingual conducting wire ligatures 1 and 2 in the field 44-43 and 33-34 of the teeth. While the chin hole remains at 0.5-1 cm posterior to the wire suture, thus avoiding damage to the same nerve. Further, between the first premolar and the canine tooth of the upper jaw at the level of the middle third of their roots on the right and left bore through DocVerse 3 and 4 in the alveolar ridge, through which the conduct of alloys 1 and 2. This location hole at back is the second allows you to avoid perforation of the maxillary sinus. At the end of the wire coming out of the holes 3 and 4 in the alveolar bone of the upper jaw with vestibular side, put the fragments subclavian catheter 4-5 cm in length, which move in the bone channels 3 and 4. Produce the reposition of fragments of the lower jaw, after which the bite is fixed in the position of Central occlusion by twisting the ends of wire ligatures. On the area of skin punctures impose an alcohol gauze, over which impose chin-parietal elastic bandage. After the operation, patients designate local hypothermia.

Fractures of the upper jaw (figure 2) the procedure is performed under endotracheal anesthesia with tracheal intubation through the nose and local infiltration anesthesia. Through punctures of the skin in the submandibular areas around the lower jaw of the vestibular and lingual conducting wire ligatures 5-8 in the field 46-47, 44-43, 33-34 and 36-37 teeth, respectively. Between the first and second molars, as well as between the first premolar and the canine tooth of the upper jaw to the right and to the left to drill four holes 9-12 in the alveolar ridge, through which the conducting wire ligatures 5-8. At the end of the wire coming out of the holes 9-12 in the alveolar bone of the upper jaw with vestibular side, put the fragments subclavian catheter 4-5 cm in length, which can move in to the local channels. Produce a mapping of the jaws in the position of Central occlusion, after which the jaw is fixed by twisting the ends of wire ligatures and perform suspension to the bones of the skull by any of the known methods. For example, through the skin wound of forehead 1.5 cm above the bridge of the nose in the front surface of the frontal bone in the midline is screwed a screw 13. Using a special Explorer to suspend one wire ligatures in the lateral divisions of the point on the transition to the crease at the level of 6-7 teeth podkulonym access to the operating wound on the skin of the forehead. The free ends of superimposed seams 5-8 in the anterior output in the wound of forehead skin along the lateral surfaces of the nose to the right and to the left. Upper jaw with fixed her jaw repairbot in the correct position, after which the wire ligature is attached to the screw 13. The wound of forehead skin is sutured. On it, as well as on the area of skin punctures impose alcohol bandages. In the postoperative period, patients are prescribed antibacterial and analgesic therapy, local hypothermia. Required to wear a chin-parietal dressing.

Special attention should be paid to the prevention of vomiting, as if rigid fixation bite the occurrence of this complication can lead to aspiration asphyxia. To prevent vomiting patients are encouraged abstinence from the of Riem alcohol and drugs, may cause vomiting; they are encouraged to constantly carry the clippers self-withdrawal of the wire sutures if vomiting occurs.

The method is illustrated by the following clinical examples.

1. Ill PM asked for help in an emergency order. When the survey was diagnosed with bilateral fracture of the mandible in the area misakomoko bone of the lower jaw to the right and 33 of the tooth, which was confirmed radiographically. Displacement of bone fragments was insignificant, malocclusion was absent. After performing anesthesia 2% R-rum lidocaine tissues of the floor of mouth in the anterior and alveolar bone of the upper jaw in the area of 13-14 and 23-24 teeth through punctures of the skin in the submandibular areas on two sides of the vestibular and lingual was conducted titanium wire in the field 44-43 and 33-34 of the teeth. Further, between the first premolar and the canine tooth of the upper jaw to the right and to the left was drilled two holes in the alveolar ridge, through which was held the wire in the palato-vestibular direction. Produced reposition of fragments of the lower jaw, after which the bite was fixed in the position of Central occlusion by twisting the ends of wire ligatures. On the area of skin punctures superimposed alcohol gauze, over which the chin-parietal elastic behavior of the lubricant. After the operation, the patient is assigned a local hypothermia. The patient was given a number of recommendations (wearing a chin-parietal dressing, oral hygiene, actions in case of vomiting). In the postoperative period assigned antibacterial, anti-inflammatory and obezbolivaushee therapy.

According to the postoperative standing radiographs of fragments regarded as satisfactory. The bite was usual, numbness in the area of innervation of the trigeminal nerve was absent, the development of inflammatory complications were noted.

The patient was observed as outpatients during the whole period of immobilization of bone fragments (5 weeks). At the outpatient stage of development of complications were observed. After removal of the wire sutures malocclusion does not arise. Took place a temporary restriction of mouth opening, which was stopped after 5 days.

At the control examination after 1 month of malocclusion, areas of numbness in the area of innervation of the trigeminal nerve, the restriction of mouth opening, reduce the level of oral hygiene were noted. By this time the patient ate nutritious food, subjectively had no complaints.

2. Patient N. was delivered to the receiving Department by ambulance. On examination, pay attention to the presence of strong malocclusion, numbness of the left side of the chin andlower lips, positive symptoms of direct and indirect stress on the lower jaw at the chin and angle to the left, the mobility of 42 teeth. After x-ray examination revealed that the fracture of the mandible in the area 41-42 and 38 teeth. There was a significant displacement of fragments. The patient was hospitalized at the Department tploc to perform osteosynthesis mini-plates.

Under endotracheal anesthesia of the fracture lines were removed 42 and 38 teeth. Mini-plates were overlaid on the jaw and fixed by two screws on each fragment in each plate. The wound sutured. After performing osteosynthesis jaw matched in Central occlusion. The next step was imposed wire sutures.

Through punctures of the skin in the submandibular areas on two sides of the vestibular and lingual was conducted titanium wire in the field 44-43 and 33-34 of the teeth. Further, between the first premolar and the canine tooth of the upper jaw to the right and left were drilled two holes in the alveolar ridge, through which held the wire in the palato-vestibular direction. The bite was not fixed in order to avoid the risk of vomiting and aspiration of vomitus during extubation and in the early postoperative period. On the area of skin punctures superimposed alcohol gauze, over which - chin-parietal elastice the Kai bandage. After the operation, the patient is assigned a local hypothermia. The next day, under local anesthesia bite was fixed in the position of Central occlusion by twisting the ends of wire ligatures.

In the postoperative period assigned antibacterial, anti-inflammatory and obezbolivaushee therapy. The patient was given a number of recommendations (wearing a chin-parietal dressing, oral hygiene, actions in case of vomiting).

According to the postoperative standing radiographs of fragments regarded as satisfactory. The bite was usual, numbness in the area of innervation of the trigeminal nerve was absent, the development of inflammatory complications were noted.

The attending physician of the hospital the patient was observed during the whole period of immobilization of bone fragments wire sutures (15 days after surgery). At the outpatient stage developed the complication was not observed. After removing the wire joints malocclusion does not arise. Numbness of the chin and lower lip, significantly decreased after surgery, were stopped completely after 3 weeks.

At the control examination after 1.5 months of malocclusion zones onemany in the area of innervation of the trigeminal nerve, the restriction of mouth opening, reduce the level of oral hygiene were noted. By this time the patient petals is full of food, subjectively had no complaints.

Mini-plates removed as scheduled. Patient recommendations on rational prosthetics.

3. Patient M had asked for help in the receiving Department in an emergency order from the trauma of the item. During the inspection were identified abocclusion, the mobility of the upper jaw when the pressure at the sky, negapatnam the edge of the right and left were determined step. Radiographically confirmed the diagnosis of a fracture of the upper jaw at an average type with two sides.

Endotracheal anaesthesia with tracheal intubation through the nose and local infiltration anesthesia.

Through the wound forehead 1.5 cm above the bridge of the nose in the front surface of the frontal bone in the midline was screwed into the screw. Next, to restore the Central occlusion through punctures of the skin in the submandibular areas around the lower jaw of the vestibular and lingual held the wire in the field 46-47, 44-43, 33-34 and 36-37 teeth. Between the first premolar and the canine tooth of the upper jaw, and between the first and second molars on the right and left drilled four holes in the alveolar ridge, through which was held wire. The jaws were mapped in the position of Central occlusion, and then fixed to each other by twisting the ends of wire ligatures. Using Windows Explorer IU is someone to suspend one wire ligatures in the lateral parts drawn from point a transitional crease at the level of 6-7 teeth podkulonym access to the operating wound on the skin of the forehead. The free ends of the sutures in the anterior were withdrawn in the wound of forehead skin along the lateral surfaces of the nose to the right and to the left. Upper jaw with fixed her jaw Rapaniana in the correct position, after which the wire ligatures were tied and attached to the screw. The wound of forehead skin sutured. On it, as well as on the area of skin punctures superimposed alcohol bandages. Extubate patient was made otsrochennoe in terms separated resuscitation in the presence of a maxillofacial surgeon in connection with the risk of vomiting. In the postoperative period the patient was assigned antibacterial, obezbolivaushee, anti-inflammatory therapy, bed rest for 10 days, local hypothermia. Recommendations for oral hygiene, wearing a chin-parietal dressing action if vomiting occurs.

As a result, the bite was recorded in the position of Central occlusion, and the mobility of the fragment removed. On the second day after the operation test x-rays (axial and paraxially projection), which was a marked improvement in the standing of fragments. Postoperative complications were noted. On the tenth day the patient was discharged to outpatient treatment under the supervision of a surgeon-dentist and neurologist at the place of residence.

After 5 months under local anesthesia with potentiation removed all fixing design. Malocclusion and limitation of mouth opening was not observed. At the control examination after a month of functional and cosmetic defects in the patient were noted. Subjective complaints of the patient is not present.

4. Patient M was delivered to the receiving Department by ambulance. During the inspection were identified mobility of the upper jaw when the pressure at the sky, negapatnam edge to the right were determined step. The patient had a complete secondary edentulous, which was filled laminar dentures on the upper and lower jaw. The prosthesis at the time of the injury suffered. Radiographically confirmed the diagnosis of a fracture of the upper jaw at an average type of the right and the top type on the left. The patient was hospitalized at the Department of maxillofacial surgery after applying a chin-parietal dressing as a means of temporary immobilization.

Anesthesia: endotracheal anaesthesia with tracheal intubation through the nose and local infiltration anesthesia.

Through the wound forehead 1.5 cm above the bridge of the nose in the front surface of the frontal bone in the midline was screwed into the screw. Using Windows Explorer to suspend one Small wire held from point a transitional fold level 16-17 teeth podkulonym access to the operating wound on the skin of the forehead above the screw and then in the vestibule of the mouth on ur the outside 26-27 teeth. The upper jaw was wearing the prosthesis. In the base of the prosthesis and the alveolar ridge of the upper jaw were drilled hole in the field 16-17, 13-14, 13-24 and 26-27 teeth. Through the holes in the lateral parts of the ends of wire ligatures were conducted from the vestibule of the oral cavity on the palatal surface of the alveolar ridge. Then they were withdrawn in the palato-vestibular direction in the vestibule of the mouth through the holes in the base of the prosthesis and in the alveolar bone in the anterior maxilla. Thereafter, the wire was held in the wound on the forehead along the side of the nose. After reposition of the upper jaw ligature was tightened, and its free ends fixed to the screw. The wound on his forehead stitched.

After complete infiltration anesthesia through punctures of the skin in the submandibular areas on two sides of the vestibular and lingual was conducted titanium wire in the projection of the holes in the base of the upper denture. Speaking of the end of the wire through the holes in the base of the upper denture and the alveolar ridge displayed in the vestibule of the mouth. To avoid the risk of vomiting and aspiration of vomitus bite was not fixed. The skin wound of forehead and point skin punctures superimposed alcohol bandages. Extubate patient produced otsrochennoe in the resuscitation Department in the presence of a maxillofacial surgeon in connection with openastromenace vomiting. The next day under local anesthesia in the lower jaw was wearing a removable denture, after which the jaws are mapped to the position of Central occlusion and the occlusion is fixed by twisting the free ends of wire ligatures.

In the postoperative period the patient was assigned antibacterial, obezbolivaushee, anti-inflammatory therapy, sedation, local hypothermia. Recommendations for oral hygiene, wearing a chin-parietal dressing action if vomiting occurs.

As a result, the bite was recorded in the usual position, and the mobility of the fragment removed. Control radiographs (axial and paraxially projection) showed improvement in the standing of fragments. Postoperative complications were found. A month and a half under local anesthesia with potentiation removed all fixing design. Malocclusion and limitation of mouth opening was not observed. At the control examination after a month functional and cosmetic disorders of the patient were observed; the patient used the newly-made prostheses. Subjective complaints of the patient is not present.

Using the proposed method allows to avoid injury to periodontal teeth and reduce the amount of metal structures in the oral cavity. The implementation is giving way possible with pronounced secondary adentia or complete absence of teeth.

1. The method of immobilization of bone fragments in fractures of the jaws, including the reposition of bone fragments and fixation of the bite in the position of Central occlusion, characterized in that the position of Central occlusion impose at least two symmetrical seam made with a wire ligatures, which cover the lower jaw and held in the holes located in the alveolar bone of the upper jaw, impose chin-parietal bandage.

2. The method according to claim 1, characterized in that the openings in the alveolar ridge install a protective tube, through which the conducting wire ligatures.



 

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