RU2370225C2 - Method of providing safe operative access to temporomandibular joint and condylar process of mandible - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to surgical dentistry and can be applied for providing safe operative access to temporomandibular joint and condylar process of mandible. Distance from point "tragion" (A) to middle of earlobe (point C) is measured. This distance is transferred onto malar arch projection, measuring it from point "tragion" (A), determining point B. Frontward of point "tragion" on malar arch projection location of superficial temporal artery is found, determining point D. Auriculotemporal (ADC) and prootic (DBC) "safety triangles" are determined.

EFFECT: method allows to take into account individual differences of anatomic structure location, reduce risk of injuring vessels and branches of facial and trigeminal nerves.

2 ex, 1 dwg

Description

The invention relates to medicine, namely to surgical dentistry.

Currently, operations on the temporomandibular joint (TMJ) and the condyle process of the lower jaw use pre-operative accesses. An analysis of the literature showed that only from pre-access can reposition and replantation of the dislocated condylar process of the lower jaw, TMJ endoprosthetics, plasty of the damaged articular disc, puncture, lavage and arthroscopy, autologous transplantation of lamellar cartilage with total crush of the disc, capsular-capsular tissue plastic mandibular joint, eliminating ankylosis and other minimally invasive interventions on the joint.

Therefore, when performing these surgical interventions on the lateral region of the face, the surgeon needs accurate knowledge of topographic anatomy, as well as projections of important anatomical formations, such as the superficial temporal artery and the same vein, branches of the facial and trigeminal nerve, and the parotid salivary gland.

By the prototype of the claimed method, the author proposes a method for providing operative access in the parotid chewing area with the allocation of a "safety triangle", which is used in surgical interventions in patients with parotid neoplasms who underwent parotidectomy with preparation of the facial nerve. // Trofimov I.G. et al. Clinical rationale for the use of conservative surgical methods in the treatment of fractures of the lower jaw branch. Magazine "TERRA MEDICA nova", archive of the application "Dentistry", 2002, No. 1 (1). S.24-25.

The proposed “safety triangle” by I. G. Trofimov and co-authors is distinguished in the parotid chewing area, in front of the auricle. The base of the triangle is 1.5 cm, facing the external auditory meatus, and its sides of the same length of 3.0 cm are facing the parotid-masticatory region.

However, the proposed "safety triangle" in the given conditions has a number of disadvantages. It has no starting points and does not take into account individual differences in the shape of the head (dolichocephalus, brachycephalus and mesocephalus). In this triangle, data on the location of the superficial temporal artery, vein, facial and trigeminal nerves are not taken into account, they are not projected onto the skin of the parotid region, therefore, there is a likelihood of damage to these anatomical structures during surgery. The authors note that the parameters of metric measurements may have different values and be inconsistent, they do not provide an explanation of these changes.

Considering the above-mentioned shortcomings of the “safety triangle”, the author proposes a method for providing quick access to the temporomandibular joint and condyle of the lower jaw using the justified “safety triangle” for reposition of bone fragments in case of damage to the condylar process of the lower jaw, as well as for minimally invasive interventions on the joint ( puncture, lavage and arthroscopy, etc.).

The technical result of the proposed method is the safety of the operation in the parotid chewing area on the TMJ and the condylar process of the lower jaw, the method will avoid the likelihood of damage to blood vessels, branches of the facial and trigeminal nerves.

To determine the starting points, the author conducted an electromyographic study to determine the location of the branches of the facial nerve.

An electromyographic study of the branches of the facial nerve was performed in 20 people aged 18–25 years, among which dolichocephals were studied in 8 cases, mesocephals in 6 cases, and brachycephals in 6 cases.

The method for determining the localization of the branches of the facial nerve was that during electrical stimulation of the branches of the facial nerve by the cutaneous irritating bipolar electrodes, a muscular response was recorded through the outlet cutaneous electrodes with subsequent recording of the evoked muscular response on an electromyograph.

The triangle is located in the parotid chewing region, all its sides are equal, and their length depends on the size of the head.

The author found that the temporal branch of the facial nerve of the first order in dolichocephalus most often was located anterior to the point “tragion” at a distance of 30 mm to 33 mm, for mesocephalus this distance was from 26 mm to 29 mm, and for brachycephalus it was from 22 mm up to 25 mm.

It was found that the distance from the “tragion” point to the temporal branch of the facial nerve of the 1st order, located at the level of the zygomatic arch, corresponds to the same distance from the above point to the site of division of the facial nerve trunk.

The study of the location of the facial nerve trunk and its temporal branch of the 1st order made it possible to identify a “safe triangle” (ABC) in the anterior zone of surgical intervention on TMJ. In this triangle, the distance from the point "tragedy" - indicated by point (A) to the place of division of the facial nerve trunk, corresponding to the middle of the earlobe and marked by point (C), is equal to the same distance from point (A) to point (B) - the intersection temporal branch of the facial nerve of the 1st order of the zygomatic arch.

The author found that in this “safe triangle” there are also two triangles in which there are no branches of the facial and trigeminal nerve. The first safe and free from the branches of the facial nerve triangle - ear-temporal - is located between the temporal branch of the facial nerve of the 1st order and the superficial temporal artery. The second safe triangle - the precancer - is located between the superficial temporal artery, the ear-temporal nerve and the point "tragion".

The method is as follows

Before the patient has access to the TMJ or the condylar process, a safe triangle (ADD) is determined for the patient. First, measure the distance from the point "tragedy" (A) to the middle of the earlobe - the point of division of the facial nerve trunk point (C), then this distance is transferred to the projection of the zygomatic arch and determine point (B) on it - the location of the temporal branch of the facial nerve of the 1st order . As a result of this, a “safe triangle” (ABC) is formed, where the distance (AC) is equal to the same distance (AB). Then, in this triangle, anterior to the “tragion” point, the location of the superficial temporal artery corresponding to point (D) is determined by palpation of the projection of the zygomatic arch. The resulting ear-temporal (ADC) and precanus (DBC) triangles are safe.

The proposed method allows to prevent damage to the branches of the facial, ear-temporal nerves, superficial temporal artery and the vein of the same name with surgical access.

Example

Patient E.A., born in 1963 (amb. Card No. 12404, no. Source. Bol. 102-2006), complained of constant pain in the TMJ on the right, radiating to the parietal and temporal region. When chewing and talking, limited opening of the mouth, the appearance of a crunch in the TMJ area with the movement of the lower jaw were noted.

After consultation, the patient was diagnosed with TMJ compression syndrome on the right, anterior displacement of the disc without reduction, myofascial pain syndrome caused by occlusal disorders.

After a laboratory-functional study and complex therapy, surgery was performed on the TMJ on the right.

Before the operation, the dimensions of the safe triangle were noted on the skin of the parotid chewing region. The distance from point (A) to point (C) was 28 mm. This size was transferred to the zygomatic arch, where point (B) was marked. Then the position of the superficial temporal artery was determined by palpation and this distance from point (A) to point (D) was 17 mm.

A patient undergoing endotracheal anesthesia underwent endotracheal anesthesia. After pretreatment of the surgical field with an alcohol solution of chlorhexedine 70% to the right in the “precautionary” safe triangle, departing from the point “tragion” 15 mm and 2 mm below the line going from it to the outer corner of the eye, an injection of the first needle with a diameter of = 1 was made, 5 mm, after which an isotonic sodium chloride solution was injected - 7 ml until the degree of decompression was determined by the appearance of an open bite in the distal dentitions on the right. Then, a second needle was injected with a diameter = 1.5 mm in the “ear-temporal” safe triangle, departing from the point “tragion” 25 mm outward and 2 mm below the line going from it to the outer corner of the eye. After the appearance of droplets of a stream of isotonic sodium chloride solution from needle No. 2 (a clinical sign of fluid circulation in the joint cavity), arthro-lavage was performed - rinsing with Ringer's solution in a volume of 100 ml - turbid washings were initially obtained, washed to obtain clean water, followed by injection 7 ml of isotonic sodium chloride solution. When performing puncture and arthro-lavage, there was no bleeding during the operation, as well as paresis of the facial muscles of the face, which indicates the absence of trauma to the branches of the facial nerve and superficial temporal artery and the same vein. In the subsequent patient, an eccentric decompression tire was installed. The patient was discharged with positive dynamics.

Thus, the proposed method for providing operative access to the TMJ and the muscular process of the lower jaw makes it possible to safely carry out an operative approach to the joint and perform joint puncture with subsequent arthrolysis without trauma to the superficial temporal artery, vein, ear-temporal and facial nerve.

Example

Patient O.R., 17 years old, medical history No. 239, complained of constant pain in the TMJ area on the left and on the right, difficulty opening the mouth and impaired movement of the lower jaw. According to the patient, she received a maxillofacial injury in childhood, as a result of which the growth zone of the condylar process of the lower jaw was damaged.

As a result of an X-ray and general clinical study, the diagnosis was made: bilateral ankylosis of TMJ.

04/09/2007, under endotracheal anesthesia, surgery was performed - bilateral removal of ankylosis with implantation of individually made joint prosthesis endoprostheses. Endoprostheses made of T1 grade titanium, individually manufactured by casting using a stereolithographic model of the patient’s facial skeleton, were used.

Before the operation, the dimensions of the safe triangle were noted on the skin of the parotid chewing region.

The distance from point (A) to point (C) was 23 mm. This size was transferred to the zygomatic arch, where point (B) was marked. Then the position of the superficial temporal artery was determined by palpation and this distance from point (A) to point (D) was 15 mm.

Surgical intervention was carried out through pre-emergency access, taking into account the “safety triangle” in the forehead section in front of the ear tragus at a distance from the point “tragion” - 10 mm. After opening the TMJ cavity and exposing the condylar process of the lower jaw, ankylosis was eliminated. At the level of the natural articular cavity with the help of a spherical cutter, a new articular platform is formed. Then, the joint fossa endoprosthesis was fixed using titanium screws and Howmedica bone cement. 2 drains were introduced into the wound, and soft tissue was sutured in layers. The postoperative period was uneventful, without complications. In the postoperative period, electromyostimulation of chewing muscles and a complex of auto-gymnastics were performed according to the classical scheme. The term of inpatient treatment was 15 days. The patient was discharged with good functional and cosmetic results.

Claims (1)

A method for providing safe operative access to the temporomandibular joint and condyle of the mandible, including determining the parameters of safe access in the parotid chewing region, characterized in that before the operation, the distance from the point “tragion” (A) to the middle of the earlobe (point C) is measured , transfer this distance to the projection of the zygomatic arch, measuring it from the point “tragion” (A), determining point B, get the isosceles “safety triangle” ABC, then in the “safety triangle” anterior to the point and "tragion" of the projection of the zygomatic arch palpation determined location of the superficial temporal artery, defining a point D, isolated ushno-temporal (ADC) and prootic (DBC) «safety triangles".

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