RU2056799C1 - Method for substituting mandibular defects - Google Patents

Abstract

FIELD: medicine. SUBSTANCE: method involves retaining distal interphalangeal joint mobility on the second radius of foot and arthrodesing proximal interphalangeal and metatarsophalangeal joint of the autograft. Distal second toe phalanx is implanted into the temporal fossa retaining a part of the temporomandibular joint capsule and three U-shaped sutures are applied over its edge to fix nail phalanx of the second toe phalanx in the temporal fossa. The crossed pterygoid and chewer muscles are sutured to the interosseous muscles of the autograft. EFFECT: improved functional results.

Description

 The invention relates to medicine, namely to maxillofacial surgery.

 A known method of osteoplastic replacement of defects of the lower jaw using as the plastic material the bones of the foot. The method was first described by Bardenheuer in 1909 (Bardenheuer: Quoted by Lexer in "Joint transplantation and arthroplasty" // Surg. Gynec. Obst. 40: 782: 1925).

 There is a method of replacing defects of the lower jaw using microsurgical autotransplantation of the 2nd ray (phalanx and metatarsal bone) of the foot (Bell M. S. G. Barron P. T. Annals of Plastic Surgery: vol. 5 1980 p. 281).

 The method consists in the fact that to replace defects in the central part of the lower jaw, as well as parts of the body and branches of the lower jaw, a free vascularized soft-bone autograft from the 2nd ray of the foot is used. An autograft is given the necessary shape and fixed in a predetermined position using Kirchner spokes held through the interphalangeal and metatarsophalangeal joint of the graft. Then the autograft is placed in the defect of the lower jaw and osteosynthesis is performed using wire sutures.

 However, this method has the following disadvantages: 1. It is impossible to restore the function of the temporomandibular joint; 2. It is impossible to restore the function of the masticatory muscles on the defect side; 3. It is impossible to achieve a good cosmetic treatment result when using this autograft to replace extensive defects of the central lower jaw.

 The purpose of the invention is to reduce treatment time, restore the function of the lower jaw and achieve a good cosmetic result of the replacement of defects in a part of the body, branch and articular process of the lower jaw.

 This goal is achieved by the fact that when a defect in a part of the body, angle, branch, and articular process of the lower jaw is replaced by a free vascularized autograft from the 2nd ray of the foot, mobility of the distal interphalangeal joint of the 2nd toe is preserved, while the proximal interphalangeal and metatarsophalangeal the autograft joints are arthrodesized, the epidermal distal phalanx of the 2nd toe is implanted in the temporal fossa, where part of the capsule of the temporomandibular joint is preserved and through its edge Gadfly three U-shaped seam, which fix the nail phalanx of the 2nd toe in the temporal fossa, crossed the wing and chewing muscles are stitched with autograft intercostals muscles, ensuring the preservation of the functions of the masticatory apparatus; the function of the temporomandibular joint is performed by the distal interphalangeal joint of the autograft.

 The operation is carried out as follows: the formation of an autograft from the 2nd ray of the foot and access to the area of the defect of the lower jaw are performed according to standard methods.

 After completion of the autograft formation, arthrodesis is performed in the 2nd metatarsophalangeal and proximal interphalangeal joints of the 2nd ray of the foot using the Kirchner needle, and the angle formed between the middle and main phalanges and metatarsal bone must exactly correspond to the angle of the patient's lower jaw. The distal interphalangeal joint of the 2nd ray of the foot remains intact. When preparing the recipient zone, it is necessary to save part of the capsule of the temporomandibular joint at the edge of the temporal fossa. Over the edge of the capsule are three U-shaped seams. After preparing the vessels of the recipient zone for anastomosis, the autograft is transferred to the recipient zone. The epidermal and deprived of the nail plate, the nail phalanx of the 2nd toe is stitched with three ligatures previously drawn through the edge of the capsule of the temporomandibular joint and immersed in the temporal fossa. Osteosynthesis is performed between the 2nd metatarsal bone and the rest of the body of the lower jaw "butt" using a tantalum wire suture. An autograft is included in the blood circulation by anastomosing the dorsal artery of the foot with the facial artery, the saphenous vein of the foot is anastomosed with the facial vein using microsurgical technique. The crossed pterygoid and chewing muscles of the recipient are stitched with the interosseous muscles of the autograft. The wounds of the recipient and donor zones are sutured in layers and drained.

 PRI me R. Patient P., 33 years old, was admitted to the microsurgery department of the Voronezh Regional Clinical Hospital, 1991 with a diagnosis of ameloblastoma of the lower jaw on the left. 7.01.91, the patient was operated on. The name of the operation is resection of a part of the body, angle, branch and articular process of the lower jaw with exarticulation on the left, transplantation of a free, vascularized autograft of the 2nd ray of the foot.

 The operation began simultaneously by two teams of surgeons. The team of the maxillofacial surgeon made access to the lower jaw, isolation of the recipient vessels of the facial artery and vein, resection of the body, angle, branch and articular process of the lower jaw with left exarticulation. The chewing and pterygoid muscles are taken on "holders". Three ligatures are drawn through the remainder of the temporomandibular joint capsule. The rest of the body of the lower jaw is prepared for osteosynthesis. Hemostasis.

 A team of microsurgeons produced the soft-bone autograft from the 2nd ray of the foot. A skin incision was made in the rear of the left foot in the projection of the dorsal artery of the foot. Subcutaneous veins, the dorsal and 1st metatarsal artery tops were highlighted. The 2nd metatarsal bone was crossed at a distance of 8 cm proximal to the metatarsophalangeal joint, the tendons of the flexors and extensors of the 2nd toe were crossed, the 2nd ray of the foot was mobilized, epidermal, the nail plate was removed, the interosseous muscles were preserved. The length of the vascular pedicle was 10 cm.

 Arthrodesis was performed using a Kirchner needle in the metatarsophalangeal and proximal interphalangeal joints of the 2nd ray of the foot. The autograft is transferred to the recipient area. The ligatures carried out earlier have stitched the soft tissues of the nail phalanx. The nail phalanx of the 2nd toe is implanted in the temporal fossa. Osteosynthesis was performed between the 2nd metatarsal bone and the remaining part of the body of the lower jaw. Using microsurgical technique, end-to-end anastomoses were applied between the dorsal artery of the foot and the facial artery (2.8 mm diameter of the vessels), between the medial saphenous vein of the foot and the facial vein (3 mm diameter). An autograft is included in the blood circulation. The chewing and pterygoid muscles of the recipient zone are stitched with the interosseous muscles of the autograft. The wounds of the maxillofacial region and the foot are sutured in layers and drained. Immobilization of the foot with a splint. Tigerstedt intermaxillary fixation. The duration of the operation was 4 hours, the time of autograft ischemia was 45 minutes.

 The postoperative period was uneventful. The wounds of the recipient and donor zones healed by primary intention. The first signs of autograft fusion with the body of the lower jaw were observed during x-ray control 10 days after surgery. Three weeks later, consolidation is complete. After removing the tires and rehabilitation therapy, a complete opening of the mouth of the patient was achieved, she was discharged home. No complications from the foot were noted.

 The use of a free vascularized soft-bone autograft from the 2nd ray of the foot to replace defects in the body, angle, branch and articular process of the lower jaw allows achieving good treatment results in a relatively short time, namely, to restore the shape of the lower jaw and the contours of the lower zone of the face, maintain the function of the temporomandibular joint and chewing muscles. An excellent cosmetic effect is achieved and the labor and social rehabilitation of patients is accelerated.

Claims (1)

 METHOD FOR REPLACING THE LOWER JAW DEFECT by means of autotransplantation of a free vascularized soft-bone complex of tissues of the 2nd ray of the foot, characterized in that, in order to reduce the treatment time, the mobility of the distal interphalangeal joint of the 2nd ray of the foot is preserved, and the proximal interphalangeal arthroplatan and metatarsophalanges , the distal phalanx of the 2nd toe is implanted in the temporal fossa, while retaining part of the capsule of the temporomandibular joint and three P-images are passed through its edge of the suture, which fix the nail phalanx of the 2nd toe in the temporal fossa, crossed pterygoid and chewing muscles are sutured with the interosseous muscles of the autograft.