Use of tension wire structures for immobilization of fragments in fractures of the lower and upper jaws

Main indications for surgery

Osteosynthesis of the jaw is carried out in situations where other more conservative methods of treating injuries do not achieve the desired result:

• for jaw fractures, which are characterized by the absence of a sufficient number of stable teeth on the fragments, as well as with significant displacement of the fragments, which makes it impossible to restore them without surgery;
• for fractures with displacement of fragments that are located directly behind the dentition;
• for jaw fractures of a pathological nature (when the fracture was the result of a neoplastic disease of bone tissue or an inflammatory process);
• with fractures of the branch and body of the lower jaw (both small- and comminuted types;
• for jaw defects in which it is possible to preserve the musculoskeletal process;
• for various types of reconstructive procedures (including indications for osteoplasty).

Comparative assessment of the effectiveness of three methods of gentle immobilization of the lower jaw for fractures

G. A. Khatskevich Doctor of Medical Sciences, Professor, Head of the Department of Pediatric Dentistry with a course of Maxillofacial Surgery at St. Petersburg State Medical University named after. acad. I. P. Pavlova (St. Petersburg)

V. G. Avetikyan Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Dentistry with a course of Maxillofacial Surgery at St. Petersburg State Medical University named after. acad. I. P. Pavlova (St. Petersburg)

I. G. Trofimov Candidate of Medical Sciences, Associate Professor of the Department of Pediatric Dentistry with a course of Maxillofacial Surgery at St. Petersburg State Medical University named after. acad. I. P. Pavlova (St. Petersburg)

Zhang Fan , doctor, postgraduate student at the Department of Pediatric Dentistry with a course in Maxillofacial Surgery at St. Petersburg State Medical University named after. acad. I. P. Pavlova (St. Petersburg)

I. Yuan Ph.D., Lecturer at Shanghai University (Shanghai, China)

V. B. Nekrasova Doctor of Medical Sciences, Professor of St. Petersburg MAPO (St. Petersburg)

Patients with injuries of the maxillofacial area make up about 30% of all patients treated in hospitals for maxillofacial surgery, while fractures of the lower jaw make up about 70-85% of all fractures of the facial bones (Ivasenko P.I., Zhurko E. P., Chekin A.V., Konvay V.D. et al., 2007; Inkarbekov Zh.B., 2009; Bakardjiev A., Pechalova P., 2007).

An analysis of data published in the scientific literature showed that the frequency of complications of mandibular fractures reaches from 10 to 41% (Mubarkova L.N., 2008; Mirsaeva F.Z., Izosimov A.A., 2009), which does not allow us to talk about effectiveness existing treatment methods.

An important pathogenetic link in the development of inflammatory complications in fractures of the lower jaw is a violation of local immune defense, regional blood circulation and innervation in the fracture zone, deterioration of oral hygiene and impaired chewing function (Timofeev A. A., 2004; Berkhman M. V., Borisova I. V., 2007; Magomedgazhiev B. G., 2008; Inkarbekov Zh. B., 2009). Moreover, these changes can be provoked not only by the injury itself, but also by inadequate fixation methods. This especially applies to round aluminum or tape dental splints. Their application is extremely traumatic for the patient and dangerous for the surgeon due to the possibility of hand injury and infection.

In addition, dental splints, used for an average of 30 days, complicate oral hygiene and injure the periodontal border. This leads to the development of pronounced inflammatory changes in the periodontium. Fractures of the lower jaw occur quite often, in which there is no displacement of the fragments and mobility is low. In this case, the immobilization provided by dental splints turns out to be redundant. In this regard, the development of gentle immobilization methods is of particular relevance.

Material and research methods

The work is based on the experience of treating 90 patients with fractures of the lower jaw. Of these, in 48 patients, the method of gentle immobilization—intermaxillary fixation using fixed orthodontic equipment—was used as the main and auxiliary (during osteosynthesis surgery) method of fixation (Fig. 1).

Rice. 1a. The stage of gluing Protekt dental buttons-braces. Immobilization of the lower jaw using elastic rings (the least traumatic method).

Rice. 1b. The stage of gluing Protekt dental buttons-braces. Immobilization of the lower jaw using elastic rings (the least traumatic method).

The comparison methods used were: immobilization of fragments with wrapping transmaxillary sutures - 18 patients (Fig. 2).

Rice. 2a. Immobilization of the lower jaw using two wire wrapped sutures.

Rice. 2b. Immobilization of the lower jaw using two wire wrapped sutures.

Intermaxillary suspension using orthodontic mini-implants - 24 patients (Fig. 3).

Rice. 3. Immobilization of the lower jaw using intraosseous implants of fixators and elastic rings.

The control group included 16 males (22.9 ± 1.2 years), practically healthy.

In the main group of patients, where Protekt braces and lingual buttons were used, biologically active additives (dietary supplements) "Lesmin" for oral administration and individual oral hygiene using dental Fitolon pastes.

For diagnosis and evaluation of results, clinical and radiological immunological, index-hygienic methods, electromyography and Doppler flowmetry were used to assess vascular microcirculation.

Indications for choosing the immobilization method using fixed orthodontic equipment (Protect) are as follows. The independent method of immobilization of the lower jaw, as an alternative to splinting, was used in the following cases: unilateral fractures without displacement or with slight displacement; bilateral fractures without displacement or with slight displacement; fracture of the condylar process without clinically detectable and functionally significant displacement (slight limitation of movements in the temporomandibular joint due to pain, the bite is not disturbed). In case of bilateral fractures of the lower jaw, in a number of cases where osteosynthesis was performed with titanium plates, bracket fixation was used as an additional method (Fig. 4).

Rice. 4. Bilateral fracture of the lower jaw. Immobilization was carried out using osteosynthesis and braces.

The analysis included only those cases where the method of gentle immobilization was used as the main method of fixation of fragments and the patients fully followed the recommendations for oral hygiene proposed by the authors. A total of 66 clinical cases were analyzed. Variants of fractures in percentage and their ratio are presented in Figure 5.

Rice. 5. Variants of mandibular fractures with gentle immobilization methods.

Research results

Patients of all 3 groups were observed from the start of treatment and for 3 months. The final assessment of treatment results was carried out 3 months after injury. Inflammatory complications were taken into account throughout the treatment. Consolidation of fragments occurred in all patients, regardless of the method of gentle immobilization. Malocclusion was detected in only one patient, whose jaw was immobilized using orthodontic mini-implants. In this case, it was possible to restore the bite by selective grinding of the teeth. The effectiveness of treatment with the methods under consideration was the same.

Inflammatory complications were observed with all methods of gentle immobilization, while in the case of using fixed orthodontic equipment (group 1), only one patient (4.2%) had a limited osteomyelitic process due to a tooth fracture left in the gap with pulp necrosis versus 12. 6% when fixed with mini-implants and 16.6% when fixed with wrapping transmaxillary sutures (Fig. 6).

Rice. 6. Frequency (%) of inflammatory complications with different methods of gentle immobilization.

In the second group (using mini-implants), 1 patient had a hematoma suppuration, and 2 patients had a limited osteomyelitic process. In the third group (wrapping transmaxillary sutures), 2 patients had suppuration of postoperative hematomas in the tissues of the floor of the mouth and one patient had chronic traumatic osteomyelitis. Thus, in the group of patients in whom gentle immobilization was performed using fixed orthodontic equipment, the number of inflammatory complications is minimal, which is due not only to less additional trauma during the procedure for immobilizing fragments, but also to the systemic use of dietary supplements.

Questionnaires to study self-assessment of quality of life were filled out by patients 1 month after the injury when the fixation structures were removed. A comparative analysis of the study results was carried out in samples of 12 patients from each group. A study of the “quality of life” profiles in patients using different methods of gentle immobilization showed that the quality of life decreases to a lesser extent in patients with fractures of the lower jaw when fixed using fixed orthodontic equipment and mini-implants (Fig. 7).

Rice. 7a. Comparative assessment of relatively healthy respondents’ QoL profiles with different methods of gentle immobilization. OTMS - wrapping transmaxillary sutures.

Rice. 7b. Comparative assessment of relatively healthy respondents’ QoL profiles with different methods of gentle immobilization. OMI - orthodontic mini-implants.

Rice. 7th century Comparative assessment of relatively healthy respondents’ QoL profiles with different methods of gentle immobilization. NOT - fixed orthodontic technique.

One month after the injury, self-assessment of the quality of life in patients with fractures of the lower jaw with a gentle method of immobilization using fixed orthodontic equipment on all scales of the physical component of health and one scale of the mental component (vitality) was higher than in patients with fixation using wrapping transmaxillary sutures.

When determining the level of oral hygiene, the Fedorov-Volodkina Hygiene Index (FHI) and the severity of periodontal inflammation according to the papillary-marginal-alveolar index (PMA) were recorded; at the initial examination, no statistically significant differences were found in patients of the three groups.

The highest RMA values ​​were found in the group of patients where fixation of fragments was carried out using wrapping transmaxillary sutures - 43.3 ± 2.4%

Subsequently, when examined after 7 days, the level of oral hygiene worsened regardless of the method of gentle immobilization and was assessed in all groups as unsatisfactory. When examined a month later, a further increase in IGPV was observed in all groups, however, in the group using fixed orthodontic technology, the increase in IGPV was found to a lesser extent - 2.4 ± 0.03 versus 2.64 ± 0.07 points (p < 0.01) in the group where fixation was carried out using orthodontic mini-implants.

Compared to the initial values, an increase in inflammation during treatment was observed in all groups of patients. At the same time, the highest RMA values ​​were established in the final study in the group of patients where the fixation of fragments was carried out using wrapping transmaxillary sutures - 43.3 ± 2.4%, and the lowest with the gentle method of immobilization we proposed using fixed orthodontic equipment - 26.4 ± 0.8% (Table No. 1).

Table No. 1. Comparative analysis of the dynamics of dental indices with gentle methods of immobilization of the lower jaw, used as the main ones.

Note: the differences relative to the initial examination are statistically significant: * - p<0.05; ** — p<0.01; *** — p<0.001; 1st time during the initial examination; 2nd time after 7 days (at discharge); 3rd time after 1 month. (when removing structures).

This result is associated with the use of surgical intervention in the comparison groups that stimulates the inflammatory response. Less severe inflammation in the final study could have been influenced by the use of the Lesmin dietary supplement by patients in the experimental group and the use of Fitolon toothpaste.

The study of factors of nonspecific protection and local immunity in the oral fluid of victims with fractures of the lower jaw during the initial examination revealed that in all groups there was a significant decrease in lysozyme activity compared to healthy individuals against the background of activation of mucosal immunity (increased levels of immunoglobulins) with a pronounced imbalance of pro- and anti-inflammatory cytokines (increased IL-8 and decreased IL-4). When examined a week later, a decrease in lysozyme activity relative to the initial data was found only in patients with entwined transmaxillary sutures (65.5 ± 2.1 versus 73.1 ± 2.3% at p < 0.01). In the same group, the lowest levels of lysozyme activity were found after a month (63.6 ± 2.2%), although upon admission in this group the activity of lysozyme was the highest (Fig. 8).

Rice. 8a. Dynamics of lysozyme and sIgA activity in patient groups. Note: NOT - 1st group, OMI - 2nd group, OTMS - 3rd group.

Rice. 8b. Dynamics of lysozyme and sIgA activity in patient groups. Note: NOT - 1st group, OMI - 2nd group, OTMS - 3rd group.

When examined after 7 days, in groups 1 and 2 the level of sIgA decreased slightly, and in group 3 it increased just as slightly. The final examination a month later showed a slight decrease (normalization) of sIgA in group 1, where we used the gentle immobilization method we proposed using fixed orthodontic equipment - 56.1 ± 3.8 versus 72.5 ± 5.78 μg/mg of protein ( p < 0.01) and 77.7 ± 11.4 μg/mg protein.

Studies have shown that when using fixed orthodontic equipment as the main method of fixation, inflammatory complications in the fracture zone are detected in 4.2% of cases

When examined after 7 days, IgG was still at high levels in all groups. Against this background, only in the experimental group of patients was there a decrease in IgM to the control level (from 2.3 ± 0.2 to 1.37 ± 0.1 μg/mg protein, with p < 0.001). A month later, a study confirmed the normalization of IgM levels only in the experimental group, where we used the gentle immobilization method we proposed using fixed orthodontic equipment (1.38 ± 0.1 versus 1.9 ± 0.13 and 2.49 ± 0.26 μg/ mg protein in comparison groups). Moreover, after a month in the experimental group, IgG decreased most significantly (3.77 ± 0.3 versus 4.6 ± 0.45 and 5.0 ± 0.4 μg/mg of protein in the comparison groups).

During the initial examination, the level of IL-8 was 9 times higher than that of the control group; in some patients it was more than 5000 pg/ml, and in some cases IL-4 was not detected at all. Against the background of such large-scale changes in the regulators of the immune response, the smallest were found in patients in the experimental group. Thus, after 7 days they showed a decrease in IL-8 (from 2707.9 ± 198.7 to 1916.3 ± 199.0 pg/ml, with p < 0.01), and when examined a month later, it was in this group has the lowest level of IL-8 (1488.2 ± 183.3 versus 1953.3 ± 202.1 and 2247.1 ± 304 pg/ml in the comparison groups) (Fig. 9).

Rice. 9. Dynamics of IL-8. Note: NOT - 1st group, OMI - 2nd group, OTMS - 3rd group.

The dynamics of IL-4 are less pronounced. In the experimental group, its amount practically does not change during treatment, remaining 2 times lower than in the control group, and in the comparison groups it further decreases. After a month, in patients of group 1, the level of IL-4 was 2.7 ± 0.2 versus 1.12 ± 0.4 and 1.0 ± 0.5 pg/ml in the comparison groups.

Thus, the study of the activity of lysozyme, mucosal immunity and the level of cytokines in the oral fluid showed that in response to a fracture of the lower jaw, the body responds with an acute-phase inflammation reaction, accompanied by a decrease in lysozyme activity against the background of activation of mucosal immunity and a pronounced imbalance of pro- and anti-inflammatory cytokines. When using the method of gentle immobilization developed by us against the background of systemic administration of the Lesmin dietary supplement, the normalization of disorders proceeds faster (in some cases, improvement occurs after 7 days), and when examined a month later, it is more pronounced, which is due to the less traumatic method of fixation and systemic administration of the biomodulator Dietary supplement "Lesmin"

conclusions

1. As a support for mandibulo-maxillary fixation, it is proposed to use non-removable orthodontic equipment: dental braces and lingual buttons, which will eliminate surgical intervention, which complicates the course of the restoration process in periodontal tissues, and will simplify and increase the effectiveness of treatment for patients with mandibular fractures.
2. When using fixed orthodontic equipment as the main method of fixation, inflammatory complications in the fracture zone were detected in 4.2% of cases. When using Fitolon toothpaste and Lesmin dietary supplement, better results were registered in comparison with the control. IGFV 2.4 + 0.03 versus 2.65 + 0.1 points at P < 0.05, and a decrease in the intensity of periodontal inflammation RMA 26.4 + 0.1 versus 36.8 + 2.0% at P < 0.001 .
3. Our data confirm the regulatory effect of cytokines in the development of inflammation. The initial increase in IL-8, as a consequence of injury, is physiologically determined and stimulates the mucosal immune system, without having a negative effect on such a factor of nonspecific defense of the oral cavity as lysozyme. However, high values ​​of IL-8 after a month negatively affect the restoration of lysozyme activity. At the same time, a decrease in the level of the anti-inflammatory cytokine IL-4, established at all stages of the study, is accompanied by an increase in lysozyme activity.
4. Restoration of lysozyme activity against the background of a decrease in elevated immunoglobulins in the oral fluid and a decrease in the degree of imbalance between pro- and anti-inflammatory cytokines leads to a decrease in the inflammatory reaction in the periodontium and an improvement in the hygienic state of the oral cavity, which confirms the effectiveness of the use of Fitolon toothpaste and the systemic use of the Lesmin dietary supplement. in patients with fractures of the lower jaw against the background of a gentle immobilization method using fixed orthodontic equipment.
5. A comparative analysis in three groups of patients with gentle immobilization showed that in the case of using fixed orthodontic equipment, the number of inflammatory complications is minimal, which is apparently due not only to less additional trauma during the procedure for immobilizing fragments, but also to the systemic use of dietary supplements. Moreover, a month after the start of treatment, these patients’ self-assessment of quality of life is higher than with other methods of gentle immobilization.
6. With the gentle immobilization method we developed, the normalization of identified violations of local nonspecific and immune defense proceeds faster - in some cases, improvement in indicators occurs within 7 days (decrease in sIgA, IgM and IL-8), and when examined a month later, the normalization is more pronounced (decrease in sIgA, IgM and IL-8 with an increase in lysozyme activity), which is due to both a less traumatic fixation technique and systemic administration of the biomodulator dietary supplement "Lesmin", which increases nonspecific resistance of the oral cavity and has an antioxidant effect.

Indications for open focal osteosynthesis

Options for performing open focal osteosynthesis of the jaw can be:

• bone suture;
• use of metal mini-plates on the bone;
• use of fast-hardening plastics.

Indications for applying a bone suture are:

• fresh fracture of the upper jaw;
• fresh fracture of the lower jaw;
• fracture of the zygomatic bone and zygomatic arch;
• jaw fractures with fragments that can be easily reduced.

With a bone suture, the patient has the opportunity to maintain oral hygiene as usual. The chewing function is preserved.

Indications for the use of mini-bone metal plates can include jaw fractures of any type. However, this method of surgical intervention cannot be used for small-comminuted fractures.

Indications for the use of fast-hardening plastics are fractures of the body of the lower jaw. The method cannot be used for comminuted fractures of the jaw, fractures of the musculoskeletal process.

We begin permanent prosthetics with metal-ceramics

In the picture you see an all-milled frame made of cobalt chrome. The photo shows the basis of the future metal-ceramic prosthesis. Based on the impressions received, the technician made a model and virtually modeled the frame for future permanent ceramic crowns. After this, the milling machine cut out a whole arch, which we must try on the patient.

Now, if everything is suitable, all parameters of the prosthetic arch meet the assigned tasks, then the technician begins lining this arch with ceramics of the desired color and desired shape. This is how the aesthetics of prosthetics is born.

Indications for closed focal osteosynthesis

Closed focal osteosynthesis can be used as a treatment for the jaw if the fragments in a non-displaced fracture can be easily reduced by hand.

Indications for the use of Kirschner wires during osteosynthesis are all minor jaw fractures with the possibility of fixing fragments using wires. In this case, the length of the spoke in the fragment should be at least 3 centimeters.

If the fracture gap is significantly tilted in the anteroposterior direction, closed osteosynthesis with a surrounding suture is indicated. The suture is made in such a way that the fragments are tightly compressed in the vertical direction and do not subsequently move relative to each other. Sometimes this method of osteosynthesis is supplemented by the application of a dentogingival prosthesis.

Features of upper jaw prosthetics

The upper jaw has a larger area for base support than the lower jaw, mainly due to the hard palate, which allows the structure to be fixed more firmly.

Adentia A large area of ​​the mucous membrane ensures suction
of a complete removable denture and guarantees its reliable attachment (this is the so-called valve zone). Thus, even with complete edentia, the upper denture will fully perform its functions, without moving during chewing or speaking, and without injuring soft tissues. When using partial structures , the chewing load is distributed more evenly, and the pressure exerted on the supporting teeth will be significantly less. Fixing the prosthesis on implants allows you to completely eliminate their mobility during operation; they are also one of the most aesthetic. However, each of them has its own indications and contraindications, which only a dentist can determine.

Crowns and bridges

The crown completely covers the tooth and allows you not only to reliably strengthen it, but also to change the shape, color and size, which is especially important for aesthetic defects.

Bridges It can also be installed on an implant or be part of a bridge.
The materials used for manufacturing are gold, metal alloys, plastic, ceramics, porcelain, zirconium. Metal crowns are more durable, but less aesthetically pleasing, so they are often installed on the side areas. Ceramic, porcelain and zirconium are highly aesthetic. This is important to consider when prosthetizing the anterior sections of the upper jaw .
Bridge structures are used to restore one or more missing teeth and, based on neighboring ones, fill the resulting space. Implants can also serve as support. Advantages: high aesthetics, strength and durability of structures, ease of care, no displacement when chewing or talking, the ability to completely change the appearance of teeth in particular and smiles in general, as well as their restoration in case of significant destruction of the coronal part. The dentist will help you make the right choice based on the situation in the oral cavity, aesthetics and cost acceptable to the patient.

Implant-supported dentures

This type of structure is fundamentally different from all those described above in that they are fixed to implants implanted into the bone of the upper jaw , which consist of a bioinert titanium alloy with a special coating. The implants themselves, after installation and engraftment, are motionless and not visible in the oral cavity. Special parts - abutments - are attached to their upper part, and the denture will be installed using two types of fixation - cement or screw.

Such designs make it possible to replace both single defects and complete edentia. In the second case, for the upper jaw the minimum number of installed implants is 4. Reliance on implants has a number of undoubted advantages: very high aesthetics, absence of bone tissue atrophy, complete immobility, durability, reliability and ease of use and care of such prostheses. It is worth noting that if replacement is necessary, the implant remains unchanged and can serve to support a different type of structure.

Benefits of performing bone augmentation in the jaw

The price for bone grafting in Moscow is affordable. When performing bone grafting of the jaw in our clinic, the price can be divided into parts due to installments. Our medical center has the following advantages:

1. Highly qualified personnel with extensive experience.
2. High level of service.
3. Convenient location of the clinic.
4. All necessary examinations in one building.
5. Quick appointment and examination.

Despite the fact that the price for bone tissue augmentation in Moscow is high, but affordable, if this operation is scheduled, it must be scheduled immediately. This is the only way to stop further destruction of the jaw. The operation restores comfort when communicating and chewing food, and it also becomes part of the treatment program before installing implants. Thanks to a high-quality foundation in the bone, implants and dentures will be fixed for decades.

You can make an appointment with a doctor by phone at a time convenient for you. The cost of the service can be clarified when visiting the reception desk or in the price list on the website