RU2281704C1 - Method for osseoeus mandibular plasty - Google Patents

Abstract

FIELD: medicine, oral surgery.

SUBSTANCE: one should perform mandibular access to model reconstructive titanium plate along external mandibular surface, mark the sites of plate's mandibular fixation being beyond the tumour to resect a tumour-affected part. Then one should apply a plate and fix it in marked sites of mandibular fixation to substitute mandibular defect with a transplant. The innovation enables to keep initial position of articular heads in articular cavities and keep maximally mouth's opening and mandibular lateral movements.

EFFECT: higher efficiency.

8 dwg, 2 ex

Description

The invention relates to medicine, namely to maxillofacial surgery, and can be used to compensate for the complex, large in length and volume of combined soft-bone defects in the lower zone of the face.

A known method of bone grafting of the lower jaw by a vascularized graft (Fu-Chan Wei, Nad Celik, Hung-Chi Chen, Ming-Huei Cheng, Wei-Chao Huang Combined anterolateral thigh flap and vascularized fibula osteoseptocutaneous flap in reconstruction of extensive composite mandibular defects. Plastic and reconstructive surgery, Vol.109, No. 1, p. 45-52, January 2002), including access to the lower jaw, resection of the tumor site, replacement of the defect with a transplant, and fixation of fragments of the lower jaw by a simulated reconstructive titanium plate. The authors use a reconstructive titanium plate to fix the bone graft and the remaining fragments of the lower jaw after resection of its area affected by the tumor. The use of a titanium plate in this case is considered as an alternative to immobilizing the lower jaw with the help of tires. The described method is adopted as a prototype.

However, with extended flaws of the lower jaw, when its angle, branch or chin is absent, it becomes difficult to maintain the true dimensions of the resulting jaw defect and fix fragments (most importantly, the articular head in the cavity) in the initial orthotopic position after removal of the tumor and bone grafting. Preservation of the orthotopic position of the fragments of the lower jaw and its articular processes is a prerequisite for achieving good functional and aesthetic results of bone grafting of the lower jaw, complete rehabilitation of the patient.

The objective of the invention is to maintain the orthotopic position of fragments of the lower jaw and its articular processes when performing bone grafting of the lower jaw.

The problem is solved in that in the method of bone grafting of the lower jaw, including access to the lower jaw, resection of the affected area of the tumor, replacing the defect with a graft and fixing fragments of the lower jaw with a simulated reconstructive titanium plate, according to the invention, after reconstructing the access to the lower jaw, the reconstructive titanium plate is modeled on the outer surface of the jaw, mark the places of fixation of the plate to the jaw outside the tumor, make a resection of the affected tumor holly section, set the plate, fix it in the marked fixation points and perform the replacement of the jaw defect with a graft.

These methods provide the necessary conditions for maintaining the initial orthotopic position of the remaining fragments of the lower jaw (including the position of the heads of the lower jaw in the articular cavities), the previous occlusion, and the true size of the resulting bone defect is recorded. Due to this, it is possible to most accurately and quickly place the bone graft in the area of the flaw of the lower jaw, while maintaining the original size of the bone defect. This approach significantly reduces the duration of the operation, reduces the time of bone graft anoxia, which favorably affects the outcome of the intervention, reduces the number of complications, improves the engraftment of the transplanted bone, creates optimal conditions for rational dental prosthetics (including on dental implants), ensuring quick recovery full chewing and mouth opening functions. In addition, the maximum possible aesthetic result of the operation is achieved. The method allows you to maintain the previous occlusion without using double jaw splinting, to significantly improve the quality of life of patients in the postoperative period: patients can easily open and close their mouths, eat food naturally, and carry out hygienic care of the oral cavity.

Figure 1-4 shows a diagram of the operation when the tumor is localized in the region of the angle of the lower jaw; figure 5-8 - with the localization of the tumor in the chin.

The method is carried out, for example, as follows.

After access to the lower jaw (external or intraoral method), the reconstructive titanium plate 1 is modeled on the outer surface of the jaw 2, the fixation points 3-6 of the plate 1 to the jaw 2 are noted outside the boundaries of the tumor 7, for example, using screws (Fig. 1, 5). After this, the screws are unscrewed, the plate 1 is removed and the tumor affected section 7 of the lower jaw is resected along the previously outlined lines 8 and 9 (Figs. 2, 6). After resection of the affected area of the tumor, the plate 1 is installed in its original place and, screwing the screws into the already existing holes 3-6, achieve the preservation of the initial position of the fragments of the lower jaw and its heads in the articular cavities (Figs. 3, 7). A vascular graft 10 is placed in the flaw zone, in a particular case, the graft 10 is connected to the stumps of the lower jaw "butt", performing osteosynthesis using titanium mini-plates, and additionally fix it with screws to the reconstruction plate 1 (Fig. 4, 8).

Reconstructive plate 1 and mini-plates used for osteosynthesis are removed after radiologically confirmed consolidation of bone fragments is achieved (8-12 months after surgery).

The method is illustrated by the following clinical examples.

1. Patient K., 35 years old, was admitted to the hospital with a diagnosis of Myxoma of the lower jaw in the chin area. Surgery was performed from the "combined" access: the main - intraoral for resection of the lower jaw and osteoplasty, an additional small size - external for the isolation of recipient vessels and the application of microvascular anastomoses.

We performed modeling of a reconstructive titanium plate along the outer surface of the jaw, marking the places where the plate was fixed to the jaw with screws, and an osteotomy of the lower jaw along two lines. After resection of the area affected by the tumor, a reconstructive plate was installed by screwing screws into the already existing holes in the preserved parts of the jaw outside the tumor area. Adaptation and osteosynthesis of the peroneal autograft with jaw stumps was performed using mini-plates with titanium screws, followed by the application of microsurgical anastomoses for revascularization. Thus, a through extended defect of the lower jaw was compensated while maintaining the remaining fragments of the lower jaw in the orthotopic position. At the same time, a graft bone graft could be placed in the position of the alveolar process of the lower jaw, and due to its modeling, it was possible to reconstruct the lost jaw segment as accurately as possible.

Wounds in the donor and recipient areas were sutured in layers, leaving tubular drainage in a vacuum.

Postoperative course without complications. Both wounds healed by primary intention. Sutures were removed on the 14th day. After 8 months, removable dentures were made, which allowed to restore the chewing function.

2. Patient I., 25 years old, was treated with a diagnosis of Ameloblastoma of the lower jaw in the body and angle on the left. Combined dento-maxillofacial anomaly. Mesial, cross, buccal bite.

On examination, asymmetry of the face, malocclusion due to displacement of the lower jaw to the right and anterior were noted.

X-ray in the area of 36-38 teeth and the angle of the lower jaw on the left determined the destruction of bone tissue and the mismatch of the central incisor lines of the upper and lower jaw,

A simultaneous operation was performed: osteotomy of the lower jaw on the right according to Dal Pont, resection of the lower jaw on the left, primary replacement of the defect of the lower jaw with the vascularized lateral edge of the scapula.

The intervention was carried out by two teams of surgeons in stages. Used combined access. Initially, from the side of the oral cavity, the following were performed: osteotomy of the lower jaw in the region of the corner and branch on the right according to Dal Pont; modeling and marking the position of the reconstructive plate outside the lower jaw tumor on the left and removing the plate for the duration of the resection. A tumor of the lower jaw was removed by intraoral access; its defect was 6 cm.

The ratio of the dentition of the upper and lower jaws (bite), set in the correct position, is fixed with the help of tooth splints. Fragments of the lower jaw in the area of the sagittal osteotomy on the right are fixed with a titanium mini-plate and on the left after the resection of the tumor in the jaw by resizing the reconstructed plate already simulated here.

To mobilize the recipient vessels in the left submandibular region, a skin and subcutaneous muscle incision of 3.5 cm was performed, a. et v. facialis, created a tunnel for conducting from an intraoral wound into the external vascular bundle of the graft. A 6.5 cm long LCL flap formed in the donor zone (feeding vascular pedicle — a. Et v. Circumflexa scapule) was cut off and transferred to the zone of defect of the lower jaw.

The graft was sized for bone defect, connected end-to-end to the stumps of the lower jaw and fixed with screws to the reconstructive plate. This part of the intervention was also performed from intraoral access.

The vascular leg of the graft through the tunnel is led into the wound of the left submandibular region, where interarterial and intervenous microanastomoses of the end-to-end type are superimposed. The wounds were sutured leaving rubber drains. Postoperative course without complications. On the 10th day, all seams were removed. The wounds healed by primary intention. Within 14 months after the operation, the necessary orthodontic measures were carried out.

5 months after the operation, full consolidation of the graft at the junction with the stumps of the lower jaw was radiologically observed. After 13 months, the reconstructive plate and miniplate, which performed osteosynthesis, were removed from the mouth.

In the future, with the help of a bridge structure, dental prosthetics was successfully carried out using dental implants as supports.

Using the invention allows to simultaneously eliminate end-to-end extended defects of the lower jaw and maintain the original occlusion, orthotopic position of the preserved fragments of the lower jaw and articular heads in the cavity. All this creates optimal conditions for the implementation of rational prosthetics (including on implants), allows maximum preservation of the opening of the mouth and lateral movements of the lower jaw, and also obtain an almost perfect aesthetic result of bone grafting.

Claims (1)

The method of bone grafting of the lower jaw, including access to the lower jaw, resection of the tumor site, replacing the defect with a graft and fixing fragments of the lower jaw with a simulated reconstructive titanium plate, characterized in that after access to the lower jaw, the reconstructive titanium plate is modeled on the outer surface of the jaw, mark the places of fixation of the plate to the jaw outside the tumor, make a resection of the area affected by the tumor, install the plate, on fixing it into selected places and operate locking jaw defect substitution graft.

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