RU2616124C1 - Method for enophthalmos correction - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: hard palate mucosa is dissected, palatal process is skeletonized, a bony canal is formed from the upper jaw alveolar bone to the maxillary sinus bottom with perforation. A metal structure is injected, consisting of the first hollow cylindrical tube, a screw and the second hollow cylindrical tube with deploying elements in the form of petals. The first cylindrical hollow tube with internal and external thread, having a sot at the lower end for the screwing tool, is screwed into the formed channel. Then, a second cylindrical tube with deploying elements in the form of petals at its upper end is placed with its lower end on the upper smooth portion of the screw against the stop on the support pad formed in the place of screw diameter increase at the transition from the smooth portion to the threaded portion with a thread corresponding to the internal thread of the first cylindrical hollow tube. At the bottom end of the screw, a hexagonal projection for the screwing tool is located. The deploying elements are reduced by the clamp and the resulting assembly is placed in the first tube. The clamp is removed and the screw is screwed in, at that, the deploying elements extend the petals at the first tub output, upon further screwing, the deploying element is brought to the top sinus wall, which is affected in order to eliminate deformation of the bottom orbit wall. A screw-cap is inserted into the lower part of the first tube. Flaps are laid in place and sutured.

EFFECT: method allows to reduce trauma due to access provision through the hard palate and availability of deploying elements, which allows to distribute the load more evenly over a larger area of the maxillary sinus upper wall bone, provides ability to remove the structure after treatment.

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Description

The invention relates to medicine, namely to maxillofacial surgery, and can be used in ophthalmology.

Post-traumatic enophthalmos, resulting from an increase in the size of the orbit or a decrease in the volume of periorbital tissue, leads to pronounced aesthetic and functional disorders in the form of binocular diplopia, decreased visual acuity. Therefore, the elimination of post-traumatic enophthalmos is one of the most difficult problems facing maxillofacial surgeons and ophthalmologists.

At the same time, in 40% of patients in the early and late postoperative period, after surgical interventions performed to eliminate defects and deformations of the walls of the orbit, enophthalmos and binocular diplopia are formed due to ongoing scarring and a decrease in peri-ocular tissue. The proposed methods for eliminating this drawback include repeated surgical treatment associated with endoprosthetics of the orbit.

There is a method of eliminating bone defects in the bottom and lower edge of the orbit with porous plates of titanium nickelide, titanium perforated plates or a titanium mesh. Through subcutaneous or transconjunctival approaches, skeletonation of the lower edge and walls of the orbit is performed. Attach a titanium mesh to the lower edge of the orbit with screws (K. A. Sivolapov, V. V. Razdorsky. Treatment of patients with fractures, deformations and defects of the jaw. Barnaul, 2011, p. 226-227).

The disadvantages of the method include its invasiveness. The use of the subcutaneous or transconjunctival approaches can lead to a shortening of the lower conjunctival fornix, inversion and retraction of the lower eyelid, formation of conjunctival cysts, transient chemosis of the bulbar conjunctiva, persistent eversion of the lower eyelid (up to 40%) of cases. Lack of revision of the maxillary sinus. Germination of fibrous tissue occurs in the perforated holes of the plate, which leads to a restriction of the movement of the eyeball, enophthalmos.

A known method of eliminating deformations and defects of the lower wall of the eye socket (according to patent No. 2526878, IPC A61F 9/007, publ. 08/27/2014, Bull. 24), which consists in installing an L-shaped titanium plate with an angle of bending of its long and short parts 90- 110 ° to the defect area. The short part is placed in a silicone block, which is fixed to it with lavsan thread. The plate is inserted through the maxillary sinus and the long part is fixed, the short part with the silicone block is installed in the area of the defect of the lower wall of the orbit.

The disadvantage of this method is the impossibility of correcting the position of the eyeball in the postoperative period.

The closest is the "Method of eliminating post-traumatic enophthalmos" (patent RU 2563588, IPC A61F 9/007, publ. 09/20/2015, Bull. No. 26). The method involves performing intra-axial access and a milling hole in the anteroposterior wall of the maxillary sinus. The method consists in using an L-shaped titanium plate located on a horizontal support installed in the region of the lower third of the milling hole. The device works on the principle of a lever. When exposed to the long part of the L-shaped plate, the short part of the plate with the silicone block is set in motion and the eyeball is moved.

The disadvantages of the method include the inability to install the plate with extensive fractures of the anterior sinus wall, the possibility of damage to the roots of the teeth and periodontium when the screw is screwed into the alveolar bone, migration of the plate due to its sliding along the support beam.

Object of the invention: the elimination of binocular diplopia and enophthalmus in the early and late postoperative periods by correcting the position of the eyeball using a metal structure, which is removed after treatment.

The task is achieved by a method of correction of enophthalmos, including access and the introduction of a metal structure of titanium in the deformation region of the lower wall of the orbit.

The mucous membrane of the hard palate is excised, the palatine process is skeletonized, the bone canal is formed from the alveolar process of the upper jaw to the bottom of the maxillary sinus with its perforation. A metal structure is introduced, consisting of a first hollow cylindrical tube, a screw and a second hollow cylindrical tube with drop-down elements in the form of petals. The first cylindrical hollow tube with an external and internal thread is screwed into the formed channel, having a socket for a screwing tool at the lower end. Then, the second cylindrical tube with the opening elements in the form of petals at the upper end is placed with the lower end on the upper smooth part of the screw against the stop on the support platform formed at the place of increasing screw diameter when moving from a smooth section to a section with a thread corresponding to the internal thread of the first cylindrical hollow tube . At the bottom of the screw is a hexagonal protrusion under the screw-in tool. The opening elements are clamped and the assembly obtained is placed in the first tube. The clamp is removed and the screw is screwed in, while the disclosing elements open the petals when they exit the first tube, and when the screw is further screwed, the expanding element is brought to the upper sinus wall and acts on it, eliminating deformation of the lower wall of the orbit. A dummy screw is inserted into the bottom of the first tube. The flaps are laid in place and sutured.

The novelty of the invention:

- The mucous membrane of the hard palate is excised, the palatine process is skeletonized, the bone channel is formed from the alveolar process of the upper jaw to the bottom of the maxillary sinus with its perforation. This access avoids damage to the roots of the teeth and periodontal when screwing the first cylindrical tube.

- Introduce a metal structure consisting of a first hollow cylindrical tube, a screw and a second hollow cylindrical tube with drop-down elements in the form of petals. When the screw is tightened, the rotational movements are not transmitted to the second hollow cylindrical tube with the opening elements, which prevents mechanical damage to the mucous membrane of the lower wall of the orbit (upper wall of the maxillary sinus).

- The presence of the opening elements in the form of petals allows you to distribute the load more evenly over a larger area of the bone of the upper wall of the maxillary sinus, which helps to avoid injury and make great efforts to move it to the desired position.

The compliance of the claimed technical solution with the criterion of "novelty" is confirmed by the presence of signs that are absent in the prototype.

The significance of the differences of the claimed method to achieve the task is confirmed by the absence in the patent and scientific literature of information about a similar method with the same set of features.

The set of essential features allows you to get a new technical result:

- reduce trauma due to access through a hard palate and the presence of disclosing elements, which allows you to distribute the load more evenly over a larger bone area of the upper wall of the maxillary sinus;

- get the ability to remove the structure after treatment;

- expand the functionality during installation in the presence of extensive fractures of the anterior wall of the maxillary sinus.

The invention is illustrated by drawings.

In FIG. 1 General view of the endoprosthesis assembly.

In FIG. 2 First hollow cylindrical tube, front view,

In FIG. 3 First hollow cylindrical tube, cut.

In FIG. 4 screw.

In FIG. 5 Second hollow cylindrical tube with drop-down elements.

In FIG. 6 Position of the structure in the wound in the sagittal plane.

The metal structure consists of a first hollow cylindrical tube 1, a screw 2 and a second hollow cylindrical tube 3 with drop-down elements 4 (Fig. 1). All structural elements are made of titanium. The first cylindrical hollow tube 1 has an external 5 and internal 6 thread. At the bottom of the tube 1 there is a socket 7 for a screw-in tool (Fig. 2, Fig. 3). The screw 2 has a thread 8 that is identical to the internal thread 6 of the hollow tube 1. In the upper part of the screw 2 there is a smooth section without thread 9, which reaches the supporting platform 10. The supporting platform 10 is formed when the smooth section 9 of the surface of the screw passes to the section with thread 8. The outer diameter of section 9 is less than 2 mm of the outer diameter of the section with thread 8 of screw 2 (Fig. 4). At the bottom of the screw is a hexagonal protrusion 11, designed to tighten the screw 2 directly into the first tube 1 (Fig. 4). The third part is represented by a second cylindrical tube 3, at the upper end of which there are opening elements 4 in the form of petals (Fig. 5). Its inner diameter corresponds to the diameter of the portion without thread 9 of screw 2, and the outer to the outer diameter of the portion with thread 8 of screw 2. Thus, due to the presence of a smooth portion without thread on the surface of screw 2, when the screw is twisted, there is no rotational movement of the second hollow cylindrical tube 3.

The method is as follows.

Before implant placement, a spiral computed tomography (CT) scan of the maxillary bones and orbits is performed, which is necessary to determine their size and configuration, and determine the degree of displacement of the eyeball. Based on the SKT data, the appropriate size of the elements of the metal structure is selected. The anteroposterior size, height (magnitude of enophthalmos) and thickness (magnitude of hypophthalmos), thickness of the hard palate, and height of the maxillary sinus are taken into account. As a result, with the help of SKT, planning of the installation of the structure, selection of size and position are made.

A method for eliminating enophthalmus involves cutting out a triangular flap of the mucous membrane of the hard palate, skeletonization of the palatine process, the formation of the bone channel with a pilot drill from the alveolar process of the upper jaw 12 to the bottom of the maxillary sinus 13 with perforation of the latter. Then produce a sequential expansion of the bone canal. The first hollow cylindrical tube 1 is screwed into the formed bone channel. The second hollow cylindrical tube 3 is placed with the lower end on the upper smooth part 9 of the screw 2 until it stops on the supporting platform 10 of the screw 2. The opening elements 4 of the second hollow cylindrical tube 3 are brought together by a clamp. The resulting assembly is placed in the first hollow cylindrical tube 1, the clamp is removed and the screw 2 is screwed into the tube 1, while the opening elements 4 are straightened when they exit the tube 1. Once in the cavity of the maxillary sinus, the expanded elements 4 of the second hollow tube 3 touch the upper wall of the sinus 13 with further screwing, as a result of which they affect the deformed area and eliminate the deformation of the orbit bottom (Fig. 6). A screw plug is screwed into the first hollow cylindrical tube with a screwdriver, the flaps are put in place and sutured. Next, the patient is sent for x-ray examination. After 30 days, repeated surgery is performed to remove the endoprosthesis. A linear incision is made in the area of the previously installed endoprosthesis of the mucosa of the hard palate with a size of about 7 mm, the screw plug is removed, the screw is unscrewed, then the first hollow tube is unscrewed and the second hollow tube with petals is removed, the wound is sutured.

Clinical example

As a clinical example, we cite an extract from the medical history of patient G., who was admitted with a diagnosis of: Postoperative deformation of the lower wall of the orbit, enophthalmos. Before surgery, a CT scan was performed, on which it was found: a comminuted fracture of the lower orbit wall with a length of 26 mm and a width of 25 mm, the lower wall of the orbit and periorbital tissues shifted by 9 mm. The left eyeball is shifted posteriorly (enophthalmos) by 6 mm, downward (hypophthalmus) by 8 mm, the left optic nerve is 6 mm lower than the right one. According to the SKT data, the elements of the endoprosthesis were selected, the first cylindrical tube 10 mm long, the screw 15 mm long, the second hollow cylindrical tube up to 12 mm long, the length of the petal 6 mm, the diameter of the second hollow cylindrical tube 4 mm, the exposure area 25.6 mm ² . During the surgical intervention, a triangular flap of the mucous membrane on the palatine process was cut out, the palatine process was skeletonized, the bone canal was formed with a pilot drill to the bottom of the maxillary sinus with perforation of the latter, and a sequential expansion of the bone canal was performed. The first hollow cylindrical tube was screwed in, the second hollow cylindrical tube was placed on the supporting platform of the screw. The opening elements 4 are brought together by a clamp. The resulting assembly was placed in a previously installed first hollow cylindrical tube, the clamp was removed and the screw 2 was screwed in. At the same time, the deformed area was affected and the deformation of the orbit bottom was eliminated. A screw plug was screwed into the first hollow cylindrical tube with a screwdriver, the flaps were put in place and the wound was sutured.

A control x-ray study of the upper jaw was carried out in a semi-axial projection on which the elimination of deformation of the lower wall of the orbit was determined, in the maxillary sinus an intensive shadow of the endoprosthesis was determined.

The patient was examined thirty days, three and six months after surgery. At the time of inspection, no complaints. The phenomenon of binocular diplopia does not bother. The eyeball is in the correct position. An ophthalmic examination revealed a slight displacement of 0.5 cm posteriorly. Thirty days after the operation, repeated surgery was performed to remove the endoprosthesis from the maxillary sinus. A linear incision was made in the area of the previously installed endoprosthesis of the mucosa of the hard palate with a size of about 7 mm, the dummy screw was removed, the screw was unscrewed, then the first hollow tube was unscrewed and the second hollow tube with petals was removed, the wound was sutured.

Thus, the use of this method allows you to eliminate enophthalmos and achieve favorable, aesthetic and functional results of treatment.

Claims (1)

The method of correction of enophthalmus, including access and the introduction of a metal structure of titanium into the deformation region of the lower wall of the orbit, characterized in that the mucous membrane of the hard palate is excised, the palatine process is skeletonized, the bone canal is formed from the alveolar process of the upper jaw to the bottom of the maxillary sinus with its perforation, a metal structure is introduced, consisting of a first hollow cylindrical tube, a screw and a second hollow cylindrical tube with expanding elements, for which they screw into the formed channel, the first cylindrical hollow tube with external and internal thread, having a socket for a screwing tool on the lower end; then the second cylindrical tube with the opening elements in the form of petals at the upper end is placed with the lower end on the upper smooth part of the screw against the stop on the support platform formed at the place of increasing screw diameter when moving from a smooth section to a section with a thread corresponding to the internal thread of the first cylindrical hollow tube , at the bottom of the screw there is a hexagonal protrusion under the screw-in tool, the drop-down elements are clamped and the assembly obtained is placed in the first tube, the clamp is removed the screw is screwed in, while the opening elements, when leaving the first tube, straighten the petals, with further screwing, the opening element is brought to the upper sinus wall and act on it, eliminating deformation of the lower wall of the orbit, a dummy screw is inserted into the lower part of the tube, flaps are laid in place and sutured.

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