RU2814406C1 - Method for elimination of defects of lower jaw body - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, particularly to maxillofacial surgery. Mucous membrane and periosteum are incised within the oral vestibule at 4–5 mm below the mucogingival line within the preserved fragments of the lower jaw and along the transitional fold within the defect. Incision is continued in the retromolar regions and further upwards, in a projection of the anterior edges of the mandibular branches. Vestibular mucoperiosteal flap is folded back within the body, external and internal mucoperiosteal flaps within the mandibular branches. Osteotomies of preserved fragments of lower jaw are performed with formation of bone fragments. Outer surface of the preserved fragments of the lower jaw body and their base are skeletonised with preserving the integrity of the mental neurovascular bundle on a large fragment of the lower jaw. External and internal surfaces of mandibular branches are skeletonized with visualization of lower jaw uvula and preservation of lower, alveolar neurovascular bundles at the entrance to mandibular foramen. Attachments of the mucous membrane, periosteum and floor muscles of the oral cavity to the inner surface of the preserved fragments of the lower jaw body are preserved. Horizontal osteotomies are performed on inner surfaces of mandibular branches at 5–6 mm from the uvula. Osteotomies are continued from front edges of branches in lower direction, along external surface of mandible body, in projection of external oblique lines. At the level of the first lower molars, the osteotomies are continued vertically downwards, reaching the base of the lower jaw body. Additional vertical osteotomy of the mandible body is performed in a projection between the second premolar and the first molar on a large preserved fragment of the mandible body. Five bone fragments are formed: two fragments of branches and three movable tooth-containing fragments of lower jaw body – one posterior and one anterior fragments of large preserved fragment and one fragment of small preserved fragment of lower jaw. Moving forward and towards the centre of the posterior fragment of the large preserved fragment and the fragment of the small preserved fragment of the lower jaw body with maintaining contact of bone surfaces along the osteotomy line. Large preserved fragment of the lower jaw is advanced and rotated to the centre of the anterior fragment. Displaced tooth-containing fragments of the lower jaw are fixed in a new position between each other and to the fragments of the branches of the lower jaw with plates and screws. Mucoperiosteal flaps are closed in the oral cavity.

EFFECT: method enables reducing the number of surgical injuries accompanying the elimination of the mandibular body defects, avoiding the inconveniences caused to the patients, as well as reducing the length of rehabilitation.

1 cl, 2 ex, 6 dwg

Description

This invention relates to medicine, namely to maxillofacial surgery, and is intended to eliminate defects in the anterior and lateral parts of the body of the lower jaw, with the possibility of subsequent orthopedic rehabilitation of patients, including the installation of dental implants and orthopedic structures supported by them.

There is a known method for replacing extensive defects of the lower jaw using a compression-distraction device.

According to the method, after applying a compression-distraction apparatus to the lower jaw, osteotomies are performed in the area of the preserved horizontal fragment of the lower jaw with the formation of several movable bone fragments 2 cm long. After a compression period of 7-10 days, each fragment is moved in the direction of the bone defect with at a rate of 1 mm per day, forming bone regenerate. The total daily movement in millimeters is equal to the number of bone fragments moved. The movement of the fragments is carried out in such a way that the fragment closest to the preserved horizontal fragment of the lower jaw stops moving and is stabilized upon reaching the chin region, the other fragment is stabilized upon reaching the area of the angle of the lower jaw, and the last fragment is moved until contact occurs with the opposite preserved fragment of the lower jaw, and in case of its absence - to the base of the skull.

If the movement of one bone fragment by a compression-distraction apparatus gives an average growth of young regenerate 1 mm per day, then the presence of several bone fragments increases this growth several times, in accordance with their number. [Patent RU 2253391 C1. Method for replacing extensive defects of the lower jaw. Author: Shvyrkov M.B. Application: November 21, 2003 Published: June 10, 2005 Bulletin. No. 16]

The disadvantage of this method is the long duration of elimination of the mandibular defect, which includes the period of formation of a young bone regenerate by compression-distraction osteogenesis, as well as the retention period for the complete maturation of the regenerate bone tissue, the duration of which is equal to at least the period of distraction, which increases the time for complete rehabilitation of patients.

Another disadvantage of this method is the use of an external compression-distraction apparatus with spokes, and the associated increased trauma of its installation, and the inconvenience of an aesthetic and functional nature caused to the patient, as well as the need for additional hygienic care for the outer parts of the apparatus and facial skin at the site of their exit out.

Another disadvantage of this method is the need for the patient to strictly follow the doctor’s recommendations, including daily independent activation of the device during the period of distraction, according to a certain schedule.

The disadvantages of this method also include a high risk of displacement of the distraction vector, given the extensiveness of the bone defect, as well as the presence of anatomical bends of the lower jaw, which can lead to deformation of the resulting bone regenerate and require additional corrective surgical interventions.

The technical result of this invention is to reduce the invasiveness of the method, the inconvenience caused to patients, as well as to reduce the time of their rehabilitation.

The technical result is achieved by the fact that in the method of eliminating defects of the body of the lower jaw by making an incision in the mucous membrane and periosteum in the area of the vestibule of the oral cavity, retreating 4-5 mm below the mucogingival line in the area of the preserved fragments of the body of the lower jaw and along the transitional fold in the area of its defect , continuing in the retromolar areas and further upward, in the projection of the anterior edges of the branches of the mandible, with the folding of the vestibular mucoperiosteal flap in the body area, and external and internal mucoperiosteal flaps in the area of the branches of the mandible, skeletonization of the outer surface of the preserved fragments of the body of the mandible and their bases, skeletonization of the external and internal surfaces of the branches of the lower jaw, performing osteotomies of the preserved fragments of the lower jaw with the formation of bone fragments, a distinctive feature is that the attachments of the mucous membrane, periosteum and muscles of the floor of the mouth to the inner surface of the preserved fragments of the body of the lower jaw are preserved, horizontal osteotomies are carried out on the internal surfaces of the branches of the lower jaw, moving upward from the tongue by 5-6 mm, which continue from the anterior edges of the branches in the lower direction, along the outer surface of the body of the lower jaw, in the projection of the external oblique lines, at the level of the first lower molars, osteotomies are continued vertically down, reaching the base of the body of the lower jaw, an additional vertical osteotomy of the body of the lower jaw is carried out in the projection between the second premolar and the first molar on a large preserved fragment of the body of the lower jaw, five bone fragments are formed: two fragments of the branches, and three movable, tooth-containing fragments of the body of the lower jaw jaws - one posterior and one anterior fragment of a large preserved fragment, and one fragment of a small preserved fragment of the body of the lower jaw, moving forward and to the center of the posterior fragment of the large preserved fragment, and a fragment of a small preserved fragment of the body of the lower jaw, maintaining contact of the bone surfaces along the line osteotomies, as well as forward advancement and rotation to the center of the anterior fragment of a large preserved fragment of the lower jaw, fix the displaced tooth-containing fragments of the lower jaw in a new position among themselves and to the fragments of the branches of the lower jaw with plates and screws, suturing mucoperiosteal flaps in the oral cavity.

The method is carried out as follows (Figure 1-6)

Before reconstructive plastic surgery, according to multislice computed tomography data, the size of the defect in the body of the lower jaw, as well as the anatomical features of its remaining fragments, are assessed. Based on computed tomography, a virtual computer simulation of the upcoming operation is carried out with the production of a bite guard for the correct positioning of the displaced osteotomized bone fragments of the lower jaw when they are fixed to each other with metal structures.

Access to the lower jaw is carried out through an incision in the mucous membrane and periosteum in the area of the vestibule of the oral cavity, retreating 4-5 mm below the muco-gingival line in the area of the preserved fragments (1) of the body of the lower jaw and along the transitional fold in the area of its defect, continuing in the retromolar areas and further upward, in the projection of the anterior edges (2) of the branches (3) of the lower jaw. The vestibular mucoperiosteal flap is folded in the area of the body, and the external and internal mucoperiosteal flaps in the area of the branches (3) of the lower jaw. The outer surface of the preserved fragments (1) of the body of the lower jaw and their base (4) are skeletonized, preserving the integrity of the mental neurovascular bundle on a large fragment of the lower jaw, if present. The outer and inner surfaces of the branches (3) of the lower jaw are skeletonized with visualization of the uvula (5) of the lower jaw and preservation of the lower, alveolar neurovascular bundles at the entrance to the mandibular foramen. The attachments of the mucous membrane, periosteum and muscles of the floor of the mouth to the inner surface of the preserved fragments (1) of the body of the lower jaw are preserved.

Horizontal osteotomies (6) are carried out on the internal surfaces of the branches (3) of the lower jaw, moving upward from the tongue (5) by 5-6 mm, which continue from the anterior edges (2) of the branches (3) in the lower direction, along the outer surface of the body of the lower jaw , in the projection of the external oblique lines (7) to the level of the first lower molars (8), which is 30-40 mm in length. This osteotomy length allows for the possible movement of bone fragments forward, while maintaining contact between the bone surfaces. At the level of the first lower molars (8), osteotomies (9) continue vertically downwards along the outer cortical plate, reaching the base (4) of the body of the lower jaw. An additional vertical (10) osteotomy of the body of the mandible, full thickness, is carried out in the projection between the second premolar (11) and the first molar (8) on a large (12) preserved fragment of the body of the mandible.

Using a chisel, the mandible is split at the level of the osteotomies with the formation of five bone fragments: two fragments of the branches (13), and three movable, tooth-containing (14) fragments of the body of the mandible - one posterior (15) and one anterior (16) fragments of the large (12) preserved fragment, and one (17) fragment of a small (18) preserved fragment of the body of the lower jaw.

Three orthodontic screws are installed in the alveolar bone of the upper and lower jaws to fix the bite. A bite positioning mouthguard is fixed on the teeth of the upper jaw, after which, by moving three tooth-containing (14) fragments of the lower jaw, the teeth of the lower jaw are inserted into it, fixing the bite, and, accordingly, the moved bone fragments in the new position with intermaxillary wire ligatures, in accordance with the planning.

The posterior (15) fragment of the large (12) preserved fragment and the fragment (17) of the small (18) preserved fragment of the body of the lower jaw are moved forward and to the center (to eliminate the defect in the lateral sections of the body of the lower jaw), while maintaining contact between the bone surfaces along osteotomy lines, as well as forward advancement and rotation to the center of the anterior (16) fragment of the large (12) preserved fragment of the lower jaw (to eliminate the defect in the anterior part of the body of the lower jaw). Considering the preservation of attachment of the mucous membrane, periosteum and muscles of the floor of the mouth to the inner surface of the tooth-containing (14) fragments of the lower jaw, they can be regarded as repositionable musculoskeletal flaps.

The displaced tooth-containing (14) fragments of the lower jaw are fixed in a new position among themselves and to the fragments of the branches (13) of the lower jaw with plates (19) and screws (20). The bite-fixing wire ligatures are cut off and the bite positioning guard is removed from the teeth.

Mucoperiosteal flaps in the oral cavity are compared and sutured together.

Example 1

Patient K. was in the Department of Maxillofacial Surgery of the Federal State Budgetary Institution National Medical Research Center "TsNIISiChLKh" with the diagnosis: "Combined defect and deformation of the middle and lower zones of the face due to a gunshot wound. Defect of the anterior and lateral part of the body of the lower jaw on the left.”

From the anamnesis it is known that 1 year ago an injury was sustained due to a gunshot wound as a result of improper handling of a gun.

During a clinical examination, a change in the configuration of the face was noted due to a combined defect and deformation of the middle and lower zones of the face, the presence of multiple scars in the perioral, buccal and submandibular areas on the left. A shift of the chin to the left was noted.

When examining the oral cavity, partial loss of teeth in the upper and lower jaws, malocclusion, and cicatricial deformation of the lower vestibule of the oral cavity were noted. Palpation revealed the presence of a defect in the anterior and lateral parts of the body of the lower jaw on the left, as well as pathological mobility of the remaining fragments of the lower jaw.

When analyzing a multislice computed tomography scan of the head, a defect in the body of the lower jaw was discovered in the anterior and lateral sections on the left, and the presence of multiple foreign bodies (shots) in the soft tissues of the face and neck.

To eliminate the defect in the body of the lower jaw, it is recommended to perform surgery using the proposed method.

According to multislice computed tomography of the head, the size of the defect in the body of the lower jaw, as well as the anatomical features of its preserved fragments, were assessed. In a computer environment, a virtual simulation of the upcoming reconstructive plastic surgery was performed, with the formation of three displaceable tooth-containing fragments of the body of the lower jaw, their positioning in a new position to eliminate the existing defect and restore the integrity of the body of the lower jaw. Taking into account the new position of the bone fragments, a bite guard was modeled for their correct positioning and fixation with metal structures during surgery. A stereolithographic bite positioning tray was fabricated for intraoperative use.

In the clinic, after a complete clinical, laboratory and instrumental examination of the patient, under combined endotracheal anesthesia, an operation was performed to eliminate the defect of the body of the lower jaw using the proposed method.

Access to the lower jaw was carried out through an incision in the mucous membrane and periosteum in the area of the vestibule of the oral cavity, retreating 4 mm below the mucogingival line in the area of the preserved fragments of the body of the lower jaw and along the transitional fold in the area of its defect, continuing in the retromolar areas and further upward, in the projection of the anterior edges of the branches of the lower jaw.

Using a raspator, the vestibular mucoperiosteal flap in the area of the body, and the external and internal mucoperiosteal flaps in the area of the branches of the lower jaw were folded back. The outer surface of the preserved fragments of the body of the lower jaw and their base were skeletonized, preserving the integrity of the mental neurovascular bundle on a large fragment of the lower jaw, on the right. The outer and inner surfaces of the branches of the mandible were skeletonized with visualization of the uvula of the mandible and preservation of the lower alveolar neurovascular bundles at the entrance to the mandibular foramen. The attachments of the mucous membrane, periosteum and muscles of the floor of the mouth to the inner surface of the preserved fragments of the body of the lower jaw were preserved.

Using a piezotome and a reciprocal saw, horizontal osteotomies were carried out on the internal surfaces of the branches of the lower jaw, moving upward from the tongue by 5 mm, which were extended from the anterior edges of the branches in the lower direction, along the outer surface of the body of the lower jaw, in the projection of the external oblique lines to the level of the first lower molars, which was 30 mm long. This length of osteotomy included the necessary movement of bone fragments forward, while maintaining contact between the bone surfaces. At the level of the first lower molars, the osteotomies were extended vertically downwards along the outer cortical plate, reaching the base of the body of the mandible. An additional vertical osteotomy of the body of the lower jaw, to the full thickness, was carried out in the projection between the second premolar and the first molar on the preserved fragment of the body of the lower jaw on the right.

Using a chisel, the mandible was split at the level of the osteotomies performed, with the formation of five bone fragments: two fragments of the branches, and three movable, tooth-containing fragments of the body of the mandible - one posterior and one anterior fragment of the preserved fragment on the right, and one fragment of the preserved fragment of the body of the mandible on the left .

Three orthodontic screws were installed in the alveolar bone of the upper and lower jaws. A bite positioning tray was fixed on the teeth of the upper jaw, after which, by moving three tooth-containing fragments of the lower jaw, the teeth of the lower jaw were brought into it, fixing the bite and the displaced bone fragments in a new position with intermaxillary wire ligatures, in accordance with the planning.

The posterior fragment of the preserved fragment of the lower jaw on the right and the fragment of the preserved fragment of the body of the lower jaw on the left were moved forward and to the center, while maintaining the contact of the bone surfaces along the osteotomy line, as well as the anterior fragment of the preserved fragment of the lower jaw was moved forward and rotated to the center on the right.

The displaced tooth-containing fragments of the lower jaw were fixed in a new position among themselves and to the fragments of the branches of the lower jaw with miniplates and miniscrews. The bite-fixing wire ligatures were cut and the bite positioning guard was removed from the teeth.

Mucoperiosteal flaps in the oral cavity were compared and sutured together.

In the postoperative period, antibacterial, anti-inflammatory, analgesic and infusion therapy, and daily dressings were administered.

As a result of the reconstructive plastic surgery, a defect in the anterior and lateral body of the lower jaw on the left was eliminated and conditions were created for subsequent orthopedic rehabilitation of the patient, with the possibility of installing dental implants and fixing orthopedic structures based on them.

Example 2

Patient D. was in the Department of Maxillofacial Surgery of the Federal State Budgetary Institution National Medical Research Center "TsNIISiChLKh" with the diagnosis: "Defect of the anterior and lateral part of the body of the lower jaw on the right. Condition after a series of operations for traumatic osteomyelitis of the lower jaw.”

From the anamnesis it is known that about 2 years ago he was injured as a result of a traffic accident with the occurrence of a comminuted fracture of the body of the lower jaw on the right. As part of first aid, metal osteosynthesis of the lower jaw was performed using plates and screws. The postoperative period was complicated by the development of traumatic osteomyelitis, for which a number of operations were performed - removal of foreign bodies, sequestrectomy, removal of non-viable tissue of the lower jaw.

During a clinical examination, a change in the configuration of the face was noted due to the retraction of soft tissues and the cheek area on the right. A displacement of the chin to the right and the presence of scars in the right submandibular region were noted.

When examining the oral cavity, partial loss of teeth in the lower jaw, malocclusion, and cicatricial deformation of the lower vestibule of the oral cavity were noted. Palpation revealed the presence of a defect in the anterior and lateral parts of the body of the lower jaw on the right, as well as pathological mobility of the preserved fragments of the lower jaw.

When analyzing a multislice computed tomogram of the head, a defect in the anterior and lateral parts of the lower jaw on the right was discovered.

In order to eliminate the defect in the body of the lower jaw, it is recommended to perform surgery using the proposed method.

According to multislice computed tomography of the head, the size of the defect in the body of the lower jaw, as well as the anatomical features of its preserved fragments, were assessed. In a computer environment, a virtual simulation of the upcoming reconstructive plastic surgery was performed, with the formation of three displaceable tooth-containing fragments of the body of the lower jaw, their positioning in a new position to eliminate the existing defect and restore the integrity of the body of the lower jaw. Taking into account the new position of the bone fragments, a bite guard was modeled for their correct positioning and fixation with metal structures during surgery. A stereolithographic bite positioning tray was manufactured for intraoperative use.

In the clinic, after a complete clinical, laboratory and instrumental examination of the patient, under combined endotracheal anesthesia, an operation was performed to eliminate the defect of the body of the lower jaw using the proposed method.

Access to the lower jaw was carried out through an incision in the mucous membrane and periosteum in the area of the vestibule of the oral cavity, retreating 5 mm below the mucogingival line in the area of the preserved fragments of the body of the lower jaw and along the transitional fold in the area of its defect, continuing in the retromolar areas and further upward, in the projection of the anterior edges of the branches of the lower jaw.

The vestibular mucoperiosteal flap in the area of the body, and the external and internal mucoperiosteal flaps in the area of the branches of the lower jaw were thrown back using a raspator. The outer surface of the preserved fragments of the body of the lower jaw and their base were skeletonized, preserving the integrity of the mental neurovascular bundle on a large fragment of the lower jaw, on the left. The outer and inner surfaces of the branches of the mandible were skeletonized with visualization of the uvula of the mandible and preservation of the lower alveolar neurovascular bundles at the entrance to the mandibular foramen. The attachments of the mucous membrane, periosteum and muscles of the floor of the mouth to the inner surface of the preserved fragments of the body of the lower jaw were preserved.

Using a piezotome and a reciprocal saw, horizontal osteotomies were carried out on the internal surfaces of the branches of the lower jaw, moving upward from the tongue by 6 mm, which were extended from the anterior edges of the branches in the lower direction, along the outer surface of the body of the lower jaw, in the projection of the external oblique lines to the level of the first lower molars, which was 40 mm long. This length of osteotomy included the necessary movement of bone fragments forward, while maintaining contact between the bone surfaces. At the level of the first mandibular molars, the osteotomies were extended vertically downward along the outer cortical plate, reaching the base of the body of the mandible. An additional vertical osteotomy of the body of the lower jaw, to the full thickness, was carried out in the projection between the second premolar and the first molar on the preserved fragment of the body of the lower jaw on the left.

Using a chisel, the mandible was split at the level of the osteotomies performed, with the formation of five bone fragments: two fragments of the branches, and three movable, tooth-containing fragments of the body of the mandible - one posterior and one anterior fragment of the preserved fragment on the left, and one fragment of the preserved fragment of the body of the mandible on the right .

Three orthodontic screws were installed in the alveolar bone of the upper and lower jaws. A bite positioning tray was fixed on the teeth of the upper jaw, after which, by moving three tooth-containing fragments of the lower jaw, the teeth of the lower jaw were brought into it, fixing the bite and the displaced bone fragments in a new position with intermaxillary wire ligatures, in accordance with the planning.

The posterior fragment of the preserved fragment of the lower jaw on the left and the fragment of the preserved fragment of the body of the lower jaw on the right were moved forward and to the center, while maintaining the contact of the bone surfaces along the osteotomy line, as well as the anterior fragment of the preserved fragment of the lower jaw was moved forward and rotated to the center on the left.

The displaced tooth-containing fragments of the lower jaw were fixed in a new position among themselves and to the fragments of the branches of the lower jaw with miniplates and miniscrews. The bite-fixing wire ligatures were cut and the bite positioning guard was removed from the teeth.

Mucoperiosteal flaps in the oral cavity were compared and sutured together.

In the postoperative period, antibacterial, anti-inflammatory, analgesic and infusion therapy, and daily dressings were administered.

As a result of the reconstructive plastic surgery, a defect in the anterior and lateral body of the lower jaw on the right was eliminated and conditions were created for subsequent orthopedic rehabilitation of the patient, with the possibility of installing dental implants and fixing orthopedic structures based on them.

The proposed method has a number of the following advantages.

Reduced trauma and - simplification due to the elimination of the defect of the body of the lower jaw in one surgical intervention, the absence of external devices for moving osteotomized bone fragments.

Reducing aesthetic and functional inconvenience caused to patients due to the absence of complex external devices, and, accordingly, the need for their periodic activation and hygienic care.

Reducing the rehabilitation time for patients due to the possibility of eliminating the defect of the body of the lower jaw in one surgical intervention, and carrying out subsequent orthopedic rehabilitation of patients, including the installation of dental implants and orthopedic structures supported by them already 3-4 months later.

Claims (1)

A method for eliminating defects in the body of the lower jaw by making an incision in the mucous membrane and periosteum in the area of the vestibule of the oral cavity, retreating 4-5 mm below the mucogingival line in the area of the preserved fragments of the lower jaw and along the transitional fold in the area of its defect, continuing in the retromolar areas and further upward in the projection of the anterior edges of the branches of the mandible with folding of the vestibular mucoperiosteal flap in the area of the body, external and internal mucoperiosteal flaps in the area of the branches of the mandible, skeletonization of the outer surface of the preserved fragments of the body of the mandible and their base, skeletonization of the outer and internal surfaces of the branches of the mandible jaw, performing osteotomies of preserved fragments of the lower jaw with the formation of bone fragments, characterized in that they preserve the attachments of the mucous membrane, periosteum and muscles of the floor of the mouth to the inner surface of the preserved fragments of the body of the lower jaw, conduct horizontal osteotomies on the internal surfaces of the branches of the lower jaw, moving away from the uvula upward by 5-6 mm, which continue from the anterior edges of the branches in the lower direction along the outer surface of the body of the lower jaw in the projection of the external oblique lines, at the level of the first lower molars, osteotomies continue vertically downwards, reaching the base of the body of the lower jaw, additional vertical osteotomy of the body of the lower jaw jaws are carried out in the projection between the second premolar and the first molar on a large preserved fragment of the body of the lower jaw, five bone fragments are formed: two fragments of branches and three movable tooth-containing fragments of the body of the lower jaw - one posterior and one anterior fragment of a large preserved fragment and one fragment of a small preserved fragment of the body of the lower jaw, moving forward and to the center of the posterior fragment of the large preserved fragment and a fragment of the small preserved fragment of the body of the lower jaw, maintaining contact of the bone surfaces along the osteotomy line, as well as advancing forward and rotating to the center of the anterior fragment of the large preserved fragment of the lower jaw, fixing the displaced tooth-containing fragments of the lower jaw in a new position between each other and to fragments of the branches of the lower jaw with plates and screws, mucoperiosteal flaps are sutured in the oral cavity.

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