颌间牵引在坚强内固定治疗复杂颌骨骨折中的应用

目的回顾46例复杂颌骨骨折开放复位坚强内固定术后的咬合关系记录，探讨颌间牵引在骨折术后咬合关系恢复中的作用。方法46例复杂的颌骨骨折，均采用开放复位坚强内固定术治疗。其中26例术前和（或）术后各1周采用颌间牵引术。术后1～3个月检查咬合关系。结果26例行颌间牵引患者咬合关系完全恢复。20例单纯坚强内固定患者有13例完全恢复，5例调合多次后基本恢复，2例调合无效最后只能通过修复治疗恢复咬合。结论在颌骨骨折治疗中短时的颌间牵引有助于咬合关系的恢复，特别是粉碎性、多发性的复杂骨折、陈旧性骨折，术前术后颌间牵引很有必要。     

自攻颌间牵引钉配合小型钛板治疗下颌骨骨折的疗效观察

目的:探讨自攻颌间牵引钉配合小型钛板治疗下颌骨骨折的临床疗效。方法:对48例下颌骨骨折患者采用自攻颌间牵引钉联合小型钛板行坚强内固定术。术后对患者的切口愈合情况、张口度、咬合关系、口腔卫生情况以及骨折愈合情况进行观察。结果:48例患者手术切口均为I期愈合,治疗效果满意,咬合关系良好,3个月后影像学复查示骨折线对位良好。结论:自攻颌间牵引钉配合小型钛板坚固内固定治疗下颌骨骨折是目前治疗下颌骨骨折较为理想的方法。     

正颌外科技术及坚强内固定治疗陈旧性下颌骨骨折

目的探讨陈旧性下颌骨骨折的治疗方法及临床疗效。方法 2010年4月-2013年3月采用正颌外科技术及坚强内固定治疗11例陈旧性下颌骨骨折。根据影像学资料进行模型外科、确定截骨部位及坚强内固定以恢复相对正常的咬合关系。术后根据X线检查结果确定骨折愈合情况,根据咬合关系、咬合力及颞下关节张口度等体征确定临床疗效。结果 11例术后均获随访,随访4~30月,平均13个月。术后6个月时X线提示骨折均愈合。10例咬合关系、咬合力及张口度良好。其中1例虽张口度及脸形良好,但咬合关节欠佳,内固定固定8个月后予正畸矫形后恢复良好。总体优良率达90.9%。结论正颌外科技术及坚强内固定为陈旧性下颌骨骨折提供二次解剖复位,对恢复正常的咬合关系、张闭口功能和颜面外形能提供可靠的保证。     

钛网塑形在15例下颌骨粉碎性骨折中的应用

目的：探讨一种下颌骨粉碎性骨折的治疗方法。方法：本组病例15例,其中13例术中依据骨折复位后的颌骨形态即刻塑形钛网;2例术前通过计算机扫描三维重建骨折区颌骨形态制作个性化钛网修复体,术中复位骨折后固定。其中5例患者术中行游离碎骨再植,恢复颌骨形态,术后观察骨折愈合情况、面型、咬合关系及张口度。结果：14例创口Ⅰ期愈合,9例患者术后随访6个月～3年,面型恢复良好、咬合关系及张口度恢复正常,总体效果满意。结论：钛网塑形固定下颌骨粉碎性骨折较重建板容易塑形,易与骨面贴合,是一种简单有效的方法。     

小型钛板坚强内固定术结合颌间牵引治疗下颌骨粉碎性骨折的研究

目的：小型钛板结合颌间牵引在治疗下颌骨粉碎性骨折中与单纯小型钛板坚强内固定术的效果比较分析。方法：下颌骨粉碎性骨折的80例患者中40例采用小型钛板坚强内固定术,40例患者采用小型钛板坚强内固定术配合颌间牵引。结果：40例小型钛板坚强内固定术结合颌间牵引在缩短手术时间,降低手术难度,骨折固位稳定性,咬合关系恢复,减少个别牙早接触等方面具有明显的改善。结论：小型钛板坚强内固定术配合颌间牵引效果优于单纯小型钛板坚强内固定术,疗效满意。     

口内入路坚强内固定治疗下颌骨体部骨折

目的：探讨下颌骨骨折手术治疗的径路及其优缺点。方法：口内切口采用小钛板坚固内固定技术治疗16例下颌骨骨折。术后1周、3个月、6个月,根据患者开口度,咬合关系,x线示骨折对位,对线情况,评估其愈合情况。结果：16例患者伤口全部I期愈合。15例咬合关系恢复到伤前咬合关系,1例出现局部咬合关系不良。术后张口度≥37mm,X线示骨折线对位良好。结论：口内入路坚固内固定治疗下颌骨骨折疗效确切,避免了面部皮肤瘢痕和面神经损伤,是治疗下颌骨骨折的有效方法。     

小型钢板固定治疗下颌骨多发性骨折

对34例下颌骨多发性骨折采用小型钢板经口内进路按 Champy 理想线固定,辅助短期颌间固定,本组病例术后经 X 线摄片检查和临床随诊观察,全部达到良好复位固定和1期愈合,2例出现切口处软组织感染;未发现咬合错乱、骨折延迟愈合和手术造成神经或牙齿损伤等并发症。提示用小型钢板单层骨皮质固定治疗下颌骨多发性骨折,方法简便,效果可靠。     

小型钢板固定治疗下颌骨多发性骨折

对３４例下颌骨多发性骨折采用小型钢板经口内进路按Ｃｈａｍｐｙ理想线固定，辅助短期颌间固定，本组病例术后经Ｘ线摄片检查和临床随诊观察，全部达到良好复位固定和Ⅰ期愈合，２例出现切口处软组织感染；未发现咬合错乱、骨折延迟愈合和手术造成神经或牙齿损伤等并发症。提示用小型钢板单层骨皮质固定治疗下颌骨多发性骨折，方法简便，效果可靠。     

小型钢板固定治疗下颌骨多发性骨折

对３４例下颌骨多发性骨折采用小型钢板经口内进路按Ｃｈａｍｐｙ理想线固定，辅助短期颌间固定，本组病例术后经Ｘ线摄片检查和临床随诊观察，全部达到良好复位固定和Ｉ期愈合，２例出现切口处软组织感染，未发现咬合错乱，骨折延迟愈合和手术造成神经或牙齿损伤等并发症。提示用小型钢板单层骨皮质固定治疗下颌骨多发性骨折，方法简便，效果可靠。     

复位内固定手术治疗全面部骨折临床疗效观察

目的探讨复位内固定手术治疗全面部骨折的临床疗效。方法对30例全面部骨折患者采取复位内固定的手术治疗并观察治疗效果。结果本组30例患者骨折均愈合良好,咬合关系完全恢复24例,基本恢复6例。开口度完全恢复患者28例,2例多发性或粉碎性骨折愈合后有轻度的咬合关系紊乱致I度开口受限。随访1~3个月,其中1例伤后4周的陈旧性骨折已错位愈合,经凿断错位愈合、重新复位内固定,咬合关系、张口度、面部外形基本恢复正常。术后未出现面神经损伤等并发症发生。结论采取复位内固定手术治疗全面部骨折遵循从下向上、由外及内复位固定顺序,重建面颅框架、面型突度及口腔咬合关系,是提高患者外型和功能恢复的重要保证。     

下颌骨多发性骨折67例临床分析

目的:探讨下颌骨多发性骨折的临床特点及治疗措施。方法:收集我科2000～2006年间住院治疗的下颌骨多发性骨折患者共67例,对其一般临床资料及治疗方法进行分析总结。结果:下颌骨多发性骨折患者男性多于女性,交通事故为第一损伤原因;伤口I期愈合、骨折对位良好、面型及功能恢复正常者64例,占95%。结论:下颌骨多发性骨折以颏正中合并髁状突、下颌角部发生较多,三维CT成像及坚固内固定技术在多发性骨折的诊断与治疗中起了较大的作用,选择合适的美学切口切开复位坚固内固定治疗效果可靠,优点明显。     

Trauma and Fracture of the Mandible

AbstractBackground: The mandible is one of the most frequently fractured bones. The objective of this prospective study was to determine and illustrate fracture patterns of the mandible in relation to various etiologic factors.Patients and Methods: A total of 218 patients with mandibular fractures were included in this study. Data regarding age, gender, causes and anatomic sites of fractures and treatment modalities were collected. Conventional plain radiographs of the mandible were obtained in all patients. The plain radiographs included such projections as Towne and Waters in patients suspected of having subcondylar fractures or associated facial fractures. Radiographs were scanned using a high-resolution scanner, and fracture lines were marked. The lines were copied and pasted to a graphic image of the mandible. All fracture lines were confirmed on surgical explorations of the fractures when the patients were under general anesthesia. Results: Traffic accidents (67%) were the most frequent cause of mandibular fractures. 51% of the patients had multiple fractures including fractures of the parasymphysis and angle, which were the most commonly affected sites (33.3%). 49% of the patients had a single fracture. The body of the mandible was the most frequently affected site in these patients (26.2%). Conclusion: Weak points of the mandible and etiologic factors were the determinants of mandibular fracture sites. We speculate that the main determinants of fracture sites were characteristics of the mandible in those fractures caused by motor vehicle accidents, while the other etiologic factors themselves determined the fracture sites for the other types of trauma.     

Surgical treatment of gunshot injuries to the mandible.

OBJECTIVES: Our goal was to review and identify risk factors for complications from treatment of mandible fractures due to gunshot wounds.Study design and setting We conducted a retrospective review of treatment outcomes in 90 patients with gunshot wounds to the mandible treated over a 10-year period at 2 tertiary care centers. RESULTS: Our series of 90 patients with mandibular injuries due to gunshot wounds included 68 patients who underwent surgical procedures on the mandible. There were 14 complications in this group. Complications were more common in patients whose mandibles were rigidly fixated; however, these patients' injuries were more severe. Complications were significantly increased in patients who lost a segment of mandible in the injury. CONCLUSIONS: Complications were related to severity of injury and independent of treatment modality. SIGNIFICANCE: The complication rate for patients with gunshot injuries can be very high, particularly if bone is missing. Stabilization of remaining mandibular segments with potentially multiple subsequent reconstructive procedures is often required to restore mandibular continuity in these patients.     

Endoscopic approach to subcondylar mandible fractures

Current interest in minimally invasive surgery has extended to the repair of craniomaxillofacial fractures, including subcondylar fractures of the mandible. Recent experience indicates that rigid fixation by the endoscopic approach is technically feasible, particularly for subcondylar fractures with lateral displacement of the proximal fragment. The technique is more difficult (although not impossible) for medially displaced fractures. High condylar fractures and comminuted fractures may not be amenable to this approach unless there is enough bone present to allow placement of screws in the proximal fragment. Because evidence suggests that the outcome of open reduction of subcondylar fractures may be better than the outcome when closed management is performed, techniques that minimize the morbidity of open reduction should allow better long-term results. It is hoped that the endoscopic approach for the repair of subcondylar fractures of the mandible will provide these benefits. The technique is summarized with step-by-step explanations.     

长管状骨骨折治疗进展

长管状骨骨折非手术治疗和手术治疗的方法各有其特点,治疗方法的选择应根据损伤的程度和性质确定。非手术治疗对于儿童骨折、成人易于手法复位的骨折及手术后的辅助治疗是较理想的选择。对于伴有严重软组织损伤的长管状骨开放性骨折、全身多发伤合并长管状骨骨折的早期救治和火器伤等,应优先采用骨外固定架治疗,而对全身情况稳定的开放性骨折、多发性骨折、多段骨折、关节内骨折及合并血管神经损伤的骨折等,应采取积极的手术治疗,并选择尽量减少对软组织血运破坏的生物学固定方法。认为今后治疗的趋势是:精心的治疗设计、微创接骨技术、良好的骨折复位、稳妥的生物学固定、早期功能锻炼,以最大限度地恢复肢体的功能。     

Avoiding occlusal derangement in facial fractures: An evidence based approach

Facial fractures with occlusal derangement describe any fracture which directly or indirectly affects the occlusal relationship. Such fractures include dento-alveolar fractures in the maxilla and mandible, midface fractures – Le fort I, II, III and mandible fractures of the symphysis, parasymphysis, body, angle, and condyle. In some of these fractures, the fracture line runs through the dento-alveolar component whereas in others the fracture line is remote from the occlusal plane nevertheless altering the occlusion. The complications that could ensue from the management of maxillofacial fractures are predominantly iatrogenic, and therefore can be avoided if adequate care is exercised by the operating surgeon. This paper does not emphasize on complications arising from any particular technique in the management of maxillofacial fractures but rather discusses complications in general, irrespective of the technique used.KEY WORDS: Complication, fracture, malocclusion, mandible, midface fracture     

Biomechanics of the facial skeleton.

Several concepts have been discussed in this article. (1) The geometry and muscle attachments of the mandible are such that it is inconsistent with physics as we know today to have this structural arrangement always in tension at the upper surface and compression always at the lower. (2) The idea behind rigid internal fixation (RIF) is to stabilize the fracture to allow the mandible to work (function) as a nonfractured structure. We should therefore attempt to simulate conditions that most accurately approximate the unfractured structure. (3) The larger, older plates worked in most situations if the fracture was reduced anatomically. As physicians use smaller devices and combinations with unicortical screws, there will be less room for error, and the stability provided by the devices will be closer to the critical load characteristics of the fractures. (4) The "neutral" axis does not remain constant in a fixed location during mastication, either in unfractured or fractured mandible scenarios. Even if a standard neutral zone existed, it would be the worst place for plate placement because devices there would not function with mechanical advantage either in tension or compression loading. (5) Tangential and comminuted fractures generally should be addressed with caution and require special attention. The probability of the smaller plates providing adequate stability in these conditions is low, and the likelihood of failure is high. Physician discretion and judgment should be used to select a more stable system if early mobilization is the goal. (6) The plating systems available rely on adequate bone apposition at the fracture site. This, coupled with a degree of compression in many scenarios, provides a stable condition under functional loading. If movement occurs at the fracture site, the load characteristics change dramatically, with much higher demands placed on the plate systems, and failures will increase based on mechanics alone. When biomechanics are not considered, the incidence of infection, nonunion, and tissue injury may increase. (7) Treatment of structural defects of the midface should be directed to the reconstruction of "normal" pretraumatic load paths. (8) When dealing with plating systems in midfacial fractures, the placement of multiple screws on each side of the fracture provides for a more even distribution of loading (load sharing between the plate and the bone). (9) Stabilization of a fracture requires prevention of translation in all three directions and rotation about all three axes. Restraining a point solves translation but not rotation. Plates provide some rotational stability. The best mechanical advantage is obtained during fixation when plates are not placed along the same axis.(ABSTRACT TRUNCATED AT 400 WORDS)     

颌面部多发性骨折的临床治疗分析

目的探讨颌面部多发性、复杂性骨折的治疗策略。方法应对非陈旧性的颌面部多发性骨折,联合神经外科、眼科、耳鼻喉科进行会诊,制定合理手术治疗方案。在骨折复位和固定治疗中,联合应用颌间结扎、钛板坚固内固定、皮瓣修复等多种技术,尽可能恢复患者的功能和面容外观。结果本组45例患者均在伤情稳定后进行骨折的整复治疗,对41处上颌骨骨折,33处下颌骨骨折,14处鼻骨骨折,12处髁突骨折,6处眶壁骨折,5处颧骨骨折进行复位和固定。术后随访3～12个月,骨折复位良好,效果满意。结论多临床学科的协同诊治有利于为患者提供更好的治疗,根据骨折的具体情况,合理选择适当的切口入路和结扎、固定方式,是颌面部多发性复杂骨折的有效治疗方法。     

Rigid internal fixation with miniplates and screws: a cost-effective technique for treating mandible fractures?

Traditional methods of fixation for stabilization of mandible fractures primarily center around intermaxillary fixation with or without open reduction. During the past decade, rigid internal fixation with miniplates and screws has attained widespread acceptance in the management of acute traumatic injuries to the mandible. With continuing emphasis on cost containment in health care delivery, plastic surgeons will be expected to justify their therapeutic methods as beneficial as well as cost-effective. This is particularly important when a number of acceptable procedures are readily available. The purpose of our investigation was retrospectively to compare treatment with intermaxillary fixation alone, interosseous wire osteosynthesis, and rigid internal fixation with miniplates and screws. We analyzed the hospital records of three such treatment groups, each consisting of 25 patients. Despite initial purchase costs, increased operating time, and the need to develop the skills required to apply the hardware, our study clearly demonstrated that miniplates and screws remain a cost-effective approach to caring for fractures of the mandible. Associated advantages include a quicker return to a preinjury life-style, decreased weight loss, improved oral hygiene and wound care, and protection of the airway, thereby eliminating monitored intensive care unit admissions.     

Ballistic impact to the forehead, zygoma, and mandible: comparison of human and frangible dummy face biomechanics

BACKGROUND: Currently, there is a greater use of nonlethal force in law enforcement and military operations. Because facial injuries have been observed, there is a need to understand the human response to ballistic impacts involving various regions of the face. This study aimed to establish blunt ballistic response corridors for high-speed, low-mass facial impacts to the forehead, zygoma, and mandible, and to determine how these responses compare with those of the frangible Hybrid III headform. Correlation of the human and dummy responses allows injury risk assessment for munitions used in the field. METHODS: Facial impacts to the forehead, zygoma, and mandible of six cadavers at 42 +/- 10 m/sec were conducted using a 25- to 35-g projectile 37 mm in diameter that was instrumented with an accelerometer to determine impact force. High-speed video analysis determined penetration of the projectile, and autopsy determined the facial fractures. Force and deflection were normalized for the 50% tile response, and corridors were determined for blunt ballistic impacts. Similar tests were conducted on the frangible face of the Hybrid III dummy. RESULTS: Peak normalized force of 3.5 +/- 0.9 kN on the forehead and 3.0 +/- 1.0 kN on the mandible did not result in fractures, whereas an impact force of 2.3 +/- 0.5 kN on the zygoma caused anterior maxilla fractures. The frangible Hybrid III face developed similar force levels, but with less penetration of the projectile. Its stiffness was 43% greater than that of the cadaver. CONCLUSIONS: Higher impact force can be tolerated on the forehead and mandible than on the zygoma. Normalized force-deflection and force-time corridors were established for the human response. The frangible Hybrid III face is an effective surrogate for assessing ballistic injury risks, but greater compliance would make it more biofidelic. Initial human tolerance levels of 6.0 kN for the forehead, 1.6 kN for the zygoma, and 1.9 kN for the mandible have been established for ballistic impacts to the face.