RU2269318C1 - Method for immobilizing fragments in case of mandibulo-maxillary fractures - Google Patents

Abstract

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

Description

The invention relates to medicine, namely to surgical dentistry, and can be used to immobilize fragments in fractures of the upper and lower jaws.

There is a method of immobilizing fragments in jaw fractures, according to which the fragments are repositioned and the bite is fixed in the central occlusion position using wire teeth, which are applied to the upper and lower jaws (MB Shvyrkov, VV Afanasyev, BC Starodubtsev. jaw fractures: A Guide. - M .: Medicine, 1999. - 336 p.). In case of fractures of the lower jaw, the bite is fixed in the central occlusion position, tying the opposite hooks of the tires on the upper and lower jaws with a rigid or elastic traction. In case of fractures of the upper jaw, the jaw is suspended to the bones of the skull.

The main disadvantage of this method is the fact that when applying and wearing tooth splints, wire structures damage the periodontal teeth. Massive wire structures cause the patient discomfort and significantly reduce the level of oral hygiene. In addition, the application of a wire splint is not always possible with severe secondary adentia or complete absence of teeth.

The objective of the invention is to provide a method for immobilizing fragments in fractures of the jaw, avoiding the injury of periodontal teeth and reduce the number of metal structures in the oral cavity.

The problem is solved in that in the method of immobilizing fragments in jaw fractures, including reposition of fragments and fixation of the occlusion in the central occlusion position, according to the invention, at least two symmetrical sutures made of wire ligatures that cover the lower ones are applied to fix the occlusion in the central occlusion position jaw and pass through holes made in the alveolar process of the upper jaw.

To prevent the penetration of bone tissue into the holes in the alveolar process, protective tubes are installed through which wire ligatures are passed.

The application of at least two symmetrical sutures made by wire ligatures that cover the lower jaw and pass through the holes made in the alveolar process of the upper jaw reliably fixes the bite in the position of central occlusion. The absence of the need for overdentation wire splints avoids the injury of periodontal teeth. At the same time, the number of metal structures in the oral cavity decreases, and the level of oral hygiene increases. The implementation of the method is possible with severe secondary adentia or complete absence of teeth. The method is simple and requires significantly less time to implement.

Figure 1 shows a diagram of a method for fractures of the lower jaw; figure 2 - with fractures of the upper jaw.

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

As the material for the seams, titanium wire with a diameter of 0.5 mm without a special coating, which has undergone dry heat sterilization, is used. To conduct a wire suture around the lower jaw, a large surgical needle is used. The holes in the upper jaw are made with a drill with a diameter of 1.7 mm. Fragments of the subclavian catheters No. 3 are put on the titanium wire, which are moved into the holes drilled in the bone to prevent wire tissue from erupting.

When fractures of the lower jaw (figure 1), the intervention is performed under infiltration anesthesia on the upper and lower jaw with a 2% solution of lidocaine. Usually, 15-20 ml of the drug was enough. After performing anesthesia through skin punctures in the submandibular regions, wire ligatures 1 and 2 are carried out vestibularly and lingually in the region of 44-43 and 33-34 teeth. In this case, the chin hole remains 0.5-1 cm posterior to the wire suture, which avoids damage to the nerve of the same name. Next, between the first premolar and the canine of the upper jaw at the level of the middle third of their roots, two holes 3 and 4 are drilled in the alveolar process through which ligatures 1 and 2 are drilled through. Such an arrangement of the holes avoids perforation of the maxillary sinus. Fragments of the subclavian catheter 4-5 cm long are put on the ends of the wire emerging from the openings 3 and 4 in the alveolar process of the upper jaw from the vestibular side, which are transferred to the bone channels 3 and 4. The lower jaw fragments are repositioned, after which the bite is fixed in position central occlusion by twisting the ends of the wire ligatures. An alcohol gauze napkin is applied to the skin puncture area, on top of which a chin-parietal elastic bandage is applied. At the end of the operation, patients are prescribed local hypothermia.

In case of fractures of the upper jaw (Fig. 2), the intervention is performed under endotracheal anesthesia with intubation of the trachea through the nose and local infiltration anesthesia. Through the punctures of the skin in the submandibular regions around the lower jaw, wire ligatures 5-8 are carried out vestibularly and lingually in the areas of 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 of the upper jaw, four holes 9-12 are drilled in the alveolar process, through which wire ligatures 5-8 are drilled on the right and left. Fragments of the subclavian catheter 4-5 cm long are inserted into the bone channels at the ends of the wire emerging from the openings 9-12 in the alveolar process of the upper jaw from the vestibular side. The jaws are compared to the central occlusion position, after which the jaws are fixed by twisting the ends of the wire ligatures and they are suspended from the skull bones using any of the known methods. For example, screw 13 is screwed through the wound of the forehead skin 1.5 cm above the bridge of the nose to the front surface of the frontal bone along the midline. Using a special conductor, the hanging wire ligatures in the lateral sections are carried out from the point on the transitional fold at the level of 6-7 teeth with surgical wound on the skin of the forehead. The free ends of the sutures 5-8 in the anterior section lead to the forehead skin wound along the lateral surfaces of the nose on the right and left. The upper jaw together with the lower jaw fixed to it is repaired in the correct position, after which the wire ligatures are attached to the screw 13. The wound of the forehead skin is sutured. Alcohol dressings are applied to it, as well as to the area of skin punctures. In the postoperative period, patients are prescribed antibacterial and analgesic therapy, local hypothermia. Be sure to wear a chin-parietal dressing.

Particular attention should be paid to the prevention of vomiting, since with a rigid fixation of the bite, the occurrence of this complication can lead to aspiration asphyxiation. To prevent vomiting, patients are advised to refrain from taking alcohol and drugs that can cause vomiting; they are encouraged to constantly carry nippers with them for self-removal of wire seams when vomiting occurs.

The method is illustrated by the following clinical examples.

1. Patient C. asked for help on an emergency basis. During the examination, a diagnosis was made of a bilateral fracture of the lower jaw in the condylar process of the lower jaw on the right and 33 teeth, which was confirmed by x-ray. The displacement of the fragments was insignificant, malocclusion was absent. After anesthesia was performed with 2% solution of lidocaine of the tissues of the bottom of the oral cavity in the anterior part and the alveolar process of the upper jaw in the region of 13-14 and 23-24 teeth through the punctures of the skin in the submandibular regions, titanium wire in the region of 44 was carried out vestibularly and lingually -43 and 33-34 teeth. Then, between the first premolar and the canine of the upper jaw on the right and left, two holes were drilled in the alveolar process, through which the wire was drawn in the palatine-vestibular direction. The reduction of fragments of the lower jaw was performed, after which the bite was fixed in the position of central occlusion by twisting the ends of the wire ligatures. An alcohol gauze napkin is placed on the skin puncture area, on top of which a chin-parietal elastic bandage. At the end of the operation, the patient was prescribed local hypothermia. The patient was given a number of recommendations (wearing a chin-parietal dressing, oral hygiene, action in case of vomiting). In the postoperative period, antibacterial, anti-inflammatory and analgesic therapy are prescribed.

According to postoperative radiographs, the standing of the fragments is regarded as satisfactory. The bite was habitual, numbness was absent in the trigeminal nerve innervation zone, and no inflammatory complications were noted.

The patient was observed on an outpatient basis throughout the period of immobilization of fragments (5 weeks). At the outpatient stage of development of complications was not observed. After removal of the wire sutures, malocclusion did not occur. There was a temporary restriction on opening the mouth, which stopped after 5 days.

During the follow-up examination after 1 month, malocclusion, numbness in the area of trigeminal nerve innervation, restrictions on opening the mouth, and a decrease in the level of oral hygiene were not observed. At this point, the patient was eating nutritious food, subjectively no complaints.

2. Patient N. was taken to the emergency room by an ambulance. On examination, the presence of a pronounced malocclusion, numbness of the left half of the chin and lower lip, positive symptoms of direct and indirect load on the lower jaw in the area of the chin and the angle on the left, and 42 tooth mobility attracted attention. After an X-ray examination, a fracture of the lower jaw was found in the area of 41-42 and 38 teeth. There was a significant displacement of fragments. The patient was hospitalized at the Department of ChLH for osteosynthesis with mini-plates.

Under endotracheal anesthesia, 42 and 38 teeth were removed from the fracture line. Mini-plates were placed on the jaw and fixed with two screws on each fragment in each plate. The wounds are sutured. After performing osteosynthesis of the jaw, it was possible to compare in central occlusion. The next step was wire seams.

Through the punctures of the skin in the submandibular regions, titanium wire was drawn in vestibularly and lingually on the 44-43 and 33-34 teeth. Then, between the first premolar and the canine of the upper jaw on the right and left, two holes were drilled in the alveolar process, through which the wire was drawn in the palatine-vestibular direction. The bite was not fixed to avoid the risk of vomiting and aspiration of vomit during extubation and in the early postoperative period. An alcohol gauze napkin is applied to the skin puncture area, on top of which is a chin-parietal elastic bandage. At the end of the operation, the patient was prescribed local hypothermia. The next day, under local anesthesia, the bite was fixed in the central occlusion position by twisting the ends of the wire ligatures.

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

According to postoperative radiographs, the standing of the fragments is regarded as satisfactory. The bite was habitual, numbness was absent in the trigeminal nerve innervation zone, and no inflammatory complications were noted.

At the attending physician of the hospital, the patient was observed during the entire period of immobilization of fragments with wire sutures (15 days from the time of surgery). At the outpatient stage, no developed complication was observed. After removal of the wire sutures, malocclusion did not occur. The numbness of the chin and lower lip, which significantly decreased after the operation, was completely stopped after 3 weeks.

During the follow-up examination after 1.5 months, malocclusion, numbness in the area of trigeminal nerve innervation, limitation of opening the mouth, and a decrease in the level of oral hygiene were not observed. At this point, the patient was eating nutritious food, subjectively no complaints.

Mini plates removed as scheduled. The patient is given recommendations on rational prosthetics.

3. Patient M. asked for help at the emergency department in an emergency direction from a trauma center. On examination, an open bite was detected, mobility of the upper jaw with pressure on the palate, a step was determined on the lower orbital edge on the right and left. Radiologically confirmed the diagnosis of a fracture of the upper jaw in the middle type on both sides.

Endotracheal anesthesia with intubation of the trachea through the nose and local infiltration analgesia.

A screw was screwed through the wound of the forehead skin 1.5 cm above the bridge of the nose into the front surface of the frontal bone in the midline. Further, to restore central occlusion through punctures of the skin in the submandibular regions around the lower jaw, a wire was conducted in the areas of 46-47, 44-43, 33-34 and 36-37 teeth in vestibular and lingual way. Between the first premolar and the canine of the upper jaw, as well as between the first and second molars on the right and left, four holes were drilled in the alveolar process through which the wire was drawn. The jaws were aligned to the central occlusion position, after which they were fixed to each other by twisting the ends of the wire ligatures. With the help of a small conductor, hanging wire ligatures in the lateral departments are drawn from a point on the transitional fold at the level of 6-7 teeth with subchip access to the surgical wound on the skin of the forehead. The free ends of the sutures in the anterior section were brought into the wound of the skin of the forehead along the lateral surfaces of the nose on the right and left. The upper jaw, together with the lower jaw fixed to it, was repaired to the correct position, after which the wire ligatures were tightened and attached to the screw. The wound of the skin of the forehead is sutured. Alcohol dressings are applied to it, as well as to the area of skin punctures. Extubation of the patient was delayed under conditions of resuscitation in the presence of a maxillofacial surgeon due to the risk of vomiting. In the postoperative period, the patient was prescribed antibacterial, analgesic, anti-inflammatory therapy, bed rest for 10 days, local hypothermia. Also given recommendations on oral hygiene, wearing a chin-parietal dressing, actions when vomiting occurs.

As a result of the operation, the bite was fixed in the position of central occlusion, and the mobility of the fragment was eliminated. On the second day after the operation, control radiographs (axial and semi-axial projections) were performed, according to which an improvement in the standing of the fragments was noted. The development of postoperative complications was not noted. On the tenth day, the patient was discharged for outpatient treatment under the supervision of a dental surgeon and a neuropathologist in the community.

After 1.5 months, all locating structures were removed under local anesthesia with potentiation. Violations of the occlusion and restrictions on opening the mouth were not observed. At the follow-up examination after a month, functional and cosmetic disorders were not observed in the patient. The patient did not present subjective complaints.

4. Patient M. was taken to the emergency room. On examination, mobility of the upper jaw with pressure on the palate was revealed, a step was determined on the lower orbital edge on the right. The patient had a complete secondary adentia, which was replaced by laminar dentures on the upper and lower jaws. Dentures were not affected at the time of the injury. Radiologically confirmed the diagnosis of a fracture of the upper jaw in the middle type on the right and upper type on the left. The patient was hospitalized in the Department of Oral and Maxillofacial Surgery after applying the chin-parietal dressing as a means of temporary immobilization.

Anesthesia: endotracheal anesthesia with intubation of the trachea through the nose and local infiltration analgesia.

A screw was screwed through the wound of the forehead skin 1.5 cm above the bridge of the nose into the front surface of the frontal bone in the midline. With the help of the Melkiy conductor, a suspension wire was drawn from a point on the transitional fold at the level of 16-17 teeth with a subjugal access to the surgical wound on the forehead skin above the screw and then on the eve of the oral cavity at the level of 26-27 teeth. A prosthesis was put on the upper jaw. In the basis of the prosthesis and the alveolar process of the upper jaw, holes were drilled in the area of 16-17, 13-14, 13-24 and 26-27 teeth. Through holes in the lateral sections, the ends of the wire ligatures were drawn from the vestibule of the oral cavity to the palatal surface of the alveolar process. Then they were brought out in the palatine-vestibular direction in the vestibule of the oral cavity through openings in the basis of the prosthesis and in the alveolar process in the frontal part of the upper jaw. After this, the wire was drawn into the wound on the forehead along the lateral surface of the nose. After repositioning of the upper jaw, the ligature was tightened, and its free ends were fixed to the screw. The wound on the forehead is sutured.

After performing an infiltration anesthesia through punctures of the skin in the submandibular regions, a titanium wire was drawn from both sides of the submandibular tongue in the projection of the holes in the base of the upper prosthesis. The lingual ends of the wire through the holes in the basis of the upper prosthesis and the alveolar process are brought out in front of the oral cavity. To avoid the risk of vomiting and aspiration of vomit, the bite was not fixed. Alcohol dressings are applied to the wound of the forehead skin and puncture points of the skin. Extubation of the patient was delayed in the intensive care unit in the presence of the maxillofacial surgeon due to the risk of vomiting. The next day, under local anesthesia, a removable denture was put on the lower jaw, after which the jaws were aligned to the central occlusion position and the bite was fixed by twisting the free ends of the wire ligatures.

In the postoperative period, the patient was prescribed antibacterial, analgesic, anti-inflammatory therapy, sedation, local hypothermia. Also given recommendations on oral hygiene, wearing a chin-parietal dressing, actions when vomiting occurs.

As a result of the operation, the bite was fixed in the usual position, and the mobility of the fragment was eliminated. Control radiographs (axial and semi-axial projections) showed an improvement in the standing of the fragments. The development of postoperative complications was not detected. After a month and a half, all locating structures were removed under local anesthesia with potentiation. Violations of the occlusion and restrictions on opening the mouth were not observed. At the follow-up examination after a month, functional and cosmetic disorders were not observed in the patient; the patient used newly made dentures. The patient did not present subjective complaints.

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

Claims (2)

1. A method of immobilizing fragments in jaw fractures, including reposition of fragments and fixation of the occlusion in the central occlusion position, characterized in that at least two symmetrical sutures are made in the position of central occlusion, made by wire ligatures that cover the lower jaw and pass through the holes located in the alveolar process of the upper jaw, impose a chin-parietal dressing. 2. The method according to claim 1, characterized in that protective tubes are inserted into the holes in the alveolar ridge, through which the wire ligatures are drawn.

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