RU2559915C1 - Method for surgical management of maxillary osteonecrosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: Kocher-Weber's surgical approach is exercised. With an anterior surface of the upper jaw and orbital bone skeletonised, peripheries of the changed bone tissue are delimited. A maxillary osteotomy extends to an infraorbital border. A preauricular approach of 3-4 cm long starts from the same side at 1-1.5 cm from a tragus and extended to a temporal region to form T-approach to a temporal muscle. A musculofascial flap is dissected and mobilised. A tunnel is created in tissues above the orbital bone and maxillary arch. The flap is delivered and stretched above the orbital bone and arch without applying an osteotome technique to the latter ones. The residual space between the muscles is filled with quickly resorbable material. The wound is closed in layers.

EFFECT: by applying the plastic repair technique using the pedicle muscle flap, the method enables providing a good stable effect, avoiding making additional osteotomy lines for the flap delivery, reducing postoperative complications.

3 dwg, 1 ex

Description

The present invention relates to medicine, in particular maxillofacial surgery, and can be used in ophthalmology, reconstructive reconstructive surgery, namely the treatment of osteonecrosis of the upper jaw.

One of the acute socio-economic problems of our time is drug addiction. The transition of young people to synthetic narcotic drugs significantly reduces the quality of life, working capacity, increases the need for specialized treatment, and also reduces the life expectancy, which leads to a decrease in the country's economic indicators. As a rule, people of working age, while taking synthetic narcotic drugs - desomorphine and pervitin, develop atypical osteomyelitis of the bones of the facial skeleton, which, according to various authors, due to the action of phosphorus in the composition of these drugs, lead to the development of toxic osteonecrosis.

The use of standard methods of treating osteomyelitis in practice does not bring the desired result, and the presence of persistent purulent discharge and exposure of bone tissue, the expansion of the boundaries of osteonecrosis, the development of maxillary abscesses and phlegmon dictates the need for surgical interventions such as extended necrectomies with jaw resection and violation of its continuity in individuals with narcotic addiction. Defects arising from this cause persistent deformations of the facial skull.

There is a method of plasty of infected bone cavities from a smaller amount of tissue of the donor segment, however, the disadvantage of this method in relation to maxillofacial surgery is the deficit of local tissues and significant size of bone cavities during resection of the upper jaw (Kudaykulov M.K. Method of plastics of infected bone cavities. Patent of Russia No. 2026647).

In people with drug addiction, while taking a synthetic drug, desomorphine is extremely problematic or impossible to use free vascular grafts to close the formed bone cavities, due to a violation of blood supply in all limbs during the administration of the drug.

There are various options for resection of the upper jaw both by the oral and external methods - Weber (Weber, 1868), Kocher (Kocher, 1880), Fergusson (Fergusson, 1949).

In the literature on maxillofacial surgery (MV Mukhin Clinical operative maxillofacial surgery. Leningrad; 1974. P. 192-199) is mentioned on page 197 that when removing the lower orbital margin and fundus of the eye socket to prevent sagging of the eyeball and preservation of binocular vision, the temporal muscle is separated from the branches of the lower jaw along with the coronoid process. After that, the muscles are laid in the form of a hammock so that it forms the bottom of the orbit. The coronoid process is fixed with catgut or polyamide thread at the inner corner of the orbit to the rest of the frontal process of the upper jaw.

The disadvantages of the method is the possibility of additional trauma to the lower jaw, which in people with drug addiction can lead to the appearance of a new zone of necrosis in the donor region, and also due to the fan-shaped form of the temporal muscle at its attachment to the coronoid process, its thickness is minimal and is represented mainly by the tendon of the temporal muscle , which is woven into the coronoid process.

The objective of the invention is a method that allows for the closure of a postoperative wound in the upper jaw and zygomatic bone, the separation of the oral cavity and nasal cavity, create an additional zone of vascularization in the surgical area, which will help reduce the number of postoperative complications and speedy rehabilitation of patients.

The problem is solved by the method of surgical treatment of osteonecrosis of the upper jaw, including osteotomy and removal of necrotic altered bone tissue of the upper jaw, isolation of the temporal muscle or temporal fascia on the feeding leg, creating a tunnel in the tissues above the zygomatic bone and zygomatic arch, without osteotomy of the latter, conducting and subsequent filling areas of osteonecrotic process by spreading the temporal muscle or temporal fascia and fixing it to the edges of the bone defect. The proposed method is illustrated by the following figures:

Fig. 1. Stage of the osteotomy of the upper jaw.

Fig. 2. The direction of the temporal muscle.

Fig. 3. The stage of spreading the flap.

The practical method is as follows. The patient lies on his back with his head turned in the direction opposite to the affected one. Quick access is used according to Kocher-Weber: the incision is made through the middle of the upper lip vertically up to the base of the septum of the nose, enveloping its wing, and then along the nasolabial fold to the inner corner of the eye. Then the incision is continued along the lower eyelid along the ciliary edge, departing from it by 2 mm, to the outer corner of the eye. An incision in the region of the lower eyelid is performed immediately with dissection of the skin and the circular muscle of the eye, then the mucous membrane of the vestibule of the oral cavity is dissected from the frenulum of the upper lip to the maxillary tubercle, and a skin-fat flap along with facial muscles is separated with a scalpel or raspator. When skeletal in the area of the infraorbital process, mobilization of the infraorbital nerve and artery is possible by performing an osteotomy or dissection of the bone with bone nippers.

Having skeletonized the front surface of the upper jaw and zygomatic bone, determined with the borders of the changed bone tissue, an osteotomy of the zygomatic bone and nasal process of the upper jaw is performed so that the lateral and medial parts of the lower orbital margin are preserved. When conducting a partial resection of the upper jaw in the area of the planned line of the osteotomy, the tooth is first removed on the affected side. Bone dissection is performed using osteotomes or using a surgical tip and various milling tips, the maxillary tubercle and pterygoid processes of the main bone are separated. If there is evidence - the presence of periosteal layers and sequestration of the cortical plates of the pterygoid processes, they are also resected. Subsequently, a purulent wound is sanitized by repeated washing with warm solutions of antiseptics, and granulation tissue is removed. A thorough hemostasis is carried out. Next, go to the next stage of surgical intervention. Gloves and operating linen are being changed. On the same side, pre-access is performed, departing from the tragus by 1-1.5 cm, 3-4 cm long, which is bent in the upper part and continues with a semicoronary or T-shaped incision. The skin flap is dissected over the tendon helmet between the two leaves of the superficial temporal fascia in order to avoid injury to the anterior temporal branch of the facial nerve. The mobilization of the flap (muscle or fascial-muscular) is subsequently carried out downward along the surface leaf of the temporal fascia to the zygomatic bone. A tunnel is created in the tissues above the zygomatic bone and zygomatic arch, without an osteotomy of the latter, along which a flap is performed. The flap is stitched with non-resorbable large threads to facilitate the conduct of muscle to the area of the defect. Another part of the flap performs the osteomyelitis cavity, the edges of the muscles are fixed to the bone by osteoperforation and fixation with non-resorbable suture material. Layer wound closure is performed. In the precancerous area, it is advisable to leave the graduate 1-2 days longer due to the long discharge in the postoperative period. In the area of the upper jaw, a prefabricated protective plate is fixed, laid on the inside with an iodine swab, which is fixed to the teeth of the opposite side with the help of clasps. The first ligation of the oral cavity is carried out 3-4 days after surgery.

Clinical example

Patient K., 26 years old, was hospitalized in a clinic with a diagnosis of Chronic osteomyelitis of the upper jaw on the right. A history of the use of a synthetic narcotic drug desomorphine was noted for 6 years. Upon receipt, the main complaint was prolonged purulent discharge and exposure of bone tissue of the upper jaw (more than 3 months). After examination, the patient under conditions of endotracheal anesthesia underwent surgery according to the proposed method on the right.

A quick access was made according to Kocher-Weber: the incision was made through the middle of the upper lip vertically up to the base of the septum of the nose, circled its wing, and then along the nasolabial fold to the inner corner of the eye. Then the incision was continued along the lower orbital margin. Next, the mucous membrane of the vestibule of the oral cavity was dissected from the frenulum of the upper lip to the maxillary tubercle on the right, a skin-fatty flap along with facial muscles was separated with a scalpel and raspator. Having skeletonized the front surface of the upper jaw and zygomatic bone, we decided on the boundaries of the changed bone tissue. Using burs and cutters, an osteotomy of the upper jaw to the lower orbital margin was performed. Subsequently, a purulent wound was sanitized by repeated washing with warm solutions of antiseptics, granulation tissue was removed. Then we proceeded to the next stage of surgical intervention. Made a change of gloves and operating linen. On the same side, pre-access was performed, departing from the tragus of the ear by 1-1.5 cm, 3-4 cm long, which was then extended into the temporal region, with the formation of a T-shaped access to the temporal muscle. Dissection and mobilization of the muscle-fascial flap 10 * 4 cm in size was performed. The flap was drawn and spread over the zygomatic bone and arch without osteotomy of the latter. The residual space between the muscles was filled with rapidly resorbable collagen-based material - Collost. Conducted layered wound closure Prolen 3-0. 4-0, Vikril 4-0. In the area of the upper jaw, a prefabricated protective plate is fixed, laid on the inside with an iodine swab, which was fixed to the teeth of the opposite side with the help of clasps. The postoperative period was uneventful, the sutures were removed on day 12.

The observation period is 2 years, without negative dynamics.

The proposed method allows to achieve stable good results, to avoid additional lines of osteotomy for the flap, to reduce postoperative complications due to plastic surgery with a muscle flap on the feeding leg, to facilitate the possible restoration of bone tissue and the speedy rehabilitation of patients.

Claims (1)

A method of surgical treatment of osteonecrosis of the upper jaw is carried out by performing an incision according to Kocher-Weber, followed by removal of necrotic-altered bone tissue of the upper jaw and cutting a muscle-fascial or fascial flap on the feeding leg from the temporal region on the same side, characterized in that the flap is carried out and stacked on top of the zygomatic bone and arch.

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