开放复位坚固内固定技术应用于髁状突骨折的临床总结
|
摘要
目的：研究开放复位坚固内固定技术用于髁状突骨折的临床效果及预后,探索髁状突骨折治疗的最优化方法,为髁状突骨折坚固内固定提供理论依据和临床指导,总结手术前后及术中注意点。
方法：回顾性调查浙江大学医学院附属第一医院口腔科(2005年9月至2010年2月)58例接受手术切开复位坚固内固定治疗的髁状突骨折病例,通过查阅病历资料、电话随访、门诊复查等手段获取所需的信息。
1.查阅病历资料及读片,了解患者年龄、性别、致伤原因、骨折类型、临床表现、有无合并其他部位骨折及手术方案等情况。
2.门诊复查或电话随访了解患者术后面形、张口度、咬合关系及术后并发症情况。
结果：随访的58例患者均接受了切开复位坚固内固定治疗,术后患者面型、咬合、关节功能等均得到改善,术后有6例患者出现暂时性面神经损伤,5例表现为患侧眼睑闭合不全,1例表现为患侧鼻唇沟变浅,均在随访期内愈合。患者对疗效满意率达93.1%。
结论：切开复位坚固内固定治疗髁状突骨折能使骨折断端得到解剖复位,充分保持骨折断端的稳定,下颌骨能进行早期、无痛的功能活动,对患者术后颞下颌关节功能的恢复有良好效果。手术入路的选择应基于保护面神经和暴露骨折断端两个原则,各种方法均有各自的优缺点,可根据实际情况选择不同的切口。术中翼外肌的解剖复位是真正恢复下颌运动的重要一环。使用小钛板、拉力螺钉、可吸收板行坚固内固定各有其适应症。不可忽视开放复位坚固内固定术后出现并发症的可能。内固定材料具有良好的生物相容性及很强的耐腐蚀性,可作为永久性植入体长期滞留体内,但临床上存在术后取板或螺钉的情况,坚固内固定是否会影响儿童下颌骨的发育还有待于长期进一步研究。
Objective:To investigate the clinical outcome and prognosis of the open reduction and rigid internal fixation for the condylar fracture patients. To conclude the clinical experience and summarize the pre and post operation management.
Method:58 cases receiving the treatment of open reduction and rigid internal fixation for condylar fractures were retrospectively reviewed, in the department of oral and maxillo-facial surgery,1st affiliated hospital, Medical Collage of Zhejiang University from September 2005 to February 2010. Information was collected by looking up medical records, telephone following up, questions answering and clinical rechecking.
1. Collecting case history for patients'gender, age, etiology, fracture type, clinical manifestation, complications and treatment schedule.
2. By telephone following-up and clinical rechecking, mouth functional et al index were recorded as well as satisfaction with treatment effect.
Result:58 cases were followed up. All patients showed great improvement on the facial type, occlusion, temporomandibular joint function, and etc.6 patients underwent the injury of facial nerve but cured during the follow-up period.93.1% of the patients were satisfied with the therapeutic effect.
Conclusion:open reduction and rigid internal fixation result in satisfactory therapeutic efficacy for the condylar fracture, but the complications cannot be ignored. The selection of operation approach should base on the conservation of facial nerves and exposure of fractures. The reduction of external pterygoid muscle is impeotant for recovery of mandibular movement.The minor titanium plates,lag screws and biodegradable plates are all favourable materias for rigid internal fixation. Some patients undergo plate removal after the operation. The influence of open reduction and rigid internal fixation to the mandibualr development in children still awaits further long-term study.
方法：回顾性调查浙江大学医学院附属第一医院口腔科(2005年9月至2010年2月)58例接受手术切开复位坚固内固定治疗的髁状突骨折病例,通过查阅病历资料、电话随访、门诊复查等手段获取所需的信息。
1.查阅病历资料及读片,了解患者年龄、性别、致伤原因、骨折类型、临床表现、有无合并其他部位骨折及手术方案等情况。
2.门诊复查或电话随访了解患者术后面形、张口度、咬合关系及术后并发症情况。
结果：随访的58例患者均接受了切开复位坚固内固定治疗,术后患者面型、咬合、关节功能等均得到改善,术后有6例患者出现暂时性面神经损伤,5例表现为患侧眼睑闭合不全,1例表现为患侧鼻唇沟变浅,均在随访期内愈合。患者对疗效满意率达93.1%。
结论：切开复位坚固内固定治疗髁状突骨折能使骨折断端得到解剖复位,充分保持骨折断端的稳定,下颌骨能进行早期、无痛的功能活动,对患者术后颞下颌关节功能的恢复有良好效果。手术入路的选择应基于保护面神经和暴露骨折断端两个原则,各种方法均有各自的优缺点,可根据实际情况选择不同的切口。术中翼外肌的解剖复位是真正恢复下颌运动的重要一环。使用小钛板、拉力螺钉、可吸收板行坚固内固定各有其适应症。不可忽视开放复位坚固内固定术后出现并发症的可能。内固定材料具有良好的生物相容性及很强的耐腐蚀性,可作为永久性植入体长期滞留体内,但临床上存在术后取板或螺钉的情况,坚固内固定是否会影响儿童下颌骨的发育还有待于长期进一步研究。
Objective:To investigate the clinical outcome and prognosis of the open reduction and rigid internal fixation for the condylar fracture patients. To conclude the clinical experience and summarize the pre and post operation management.
Method:58 cases receiving the treatment of open reduction and rigid internal fixation for condylar fractures were retrospectively reviewed, in the department of oral and maxillo-facial surgery,1st affiliated hospital, Medical Collage of Zhejiang University from September 2005 to February 2010. Information was collected by looking up medical records, telephone following up, questions answering and clinical rechecking.
1. Collecting case history for patients'gender, age, etiology, fracture type, clinical manifestation, complications and treatment schedule.
2. By telephone following-up and clinical rechecking, mouth functional et al index were recorded as well as satisfaction with treatment effect.
Result:58 cases were followed up. All patients showed great improvement on the facial type, occlusion, temporomandibular joint function, and etc.6 patients underwent the injury of facial nerve but cured during the follow-up period.93.1% of the patients were satisfied with the therapeutic effect.
Conclusion:open reduction and rigid internal fixation result in satisfactory therapeutic efficacy for the condylar fracture, but the complications cannot be ignored. The selection of operation approach should base on the conservation of facial nerves and exposure of fractures. The reduction of external pterygoid muscle is impeotant for recovery of mandibular movement.The minor titanium plates,lag screws and biodegradable plates are all favourable materias for rigid internal fixation. Some patients undergo plate removal after the operation. The influence of open reduction and rigid internal fixation to the mandibualr development in children still awaits further long-term study.
引文
[1]Nicholas Z, Michael M, Constintine M, et al. Fractures of the mandibular condyle:A review of 466 cases. Literature review, reflections on treatment and proposals. Journal of Cranio-Maxillofacial Surgery,2006,34, (7):421-432.
[2]Williams JG, Cawood JL. Effects of inter maxillary fixation on pulmonary function. Int J Oral Maxillofac Surg,1990,19(2):76-78.
[3]Schilli W, Luhr HG. Rigid internal fixation by means of compression plates. Oral and Maxillofacial Traumatology, Kruger E, Schilli. Chicago, Quintessence, 1982:195-196.
[4]李冬仙,张印斗,柳新华.髁状突骨折治疗效果的临床分析.口腔医学纵横,2001,17(4)：316.
[5]Palmieri C, Ellis E, Throckmorton G. Mandibular nation after closed and open treatment of unilateral mandibular condglar process fractures. J Oral Maxillofac Surg,1999,57(6):764.
[6]Silvennoinen U, Raustia AM, Lindqvist C, et al. Occlusal and temporomandibular joint disorders in patients with unilateral condylar fracture. A prospective one year study. Int J Oral Maxillofac Surg,1998,27(4):280-285.
[7]张益,张陈平.颌骨外科与AO内固定新进展-颌骨骨折治疗.口腔颌面外科杂志,2000,10(1)：41-43.
[8]Champy M, Lodde JP, Jaeger JH, et al. Mandibular osteosynthesis according to the Michelet technique. I. Biomechanical bases. Rev Stomatol Chir Maxlillofac,1976, 77(3):569-576.
[9]张益,张兴文.髁状突骨折解剖复位及小接骨板坚固内固定.中华口腔医学杂志.2001,36(2)：99-101.
[10]张志光,许跃,何一青,等.髁状突颈部骨折手术疗法和保守疗法近期疗效评价.现代口腔医学杂志；2001,15(5)：384-38.
[11]Choi B, Kim K, Kim H, et al. An in vitro evaluation of condylar neek fraeture plating techniques. Int J Oral Maxillofac Surg.1999,28(Suppl):78-81.
[12]Ellis E. Treatment methods for fractures of the mandibular angle. Int J oral Maxillofac Surg.1999:28(4):243-252.
[13]Brons R, Boering G. Fractures of the mandibular body treated by stable internal fixation:A preliminary report. J oral Surg.1970,28(6):407-415.
[14]Teranobu O, Yamada K, Eida K, et al. Evaluation of lag screw osteosynthesis for condylar process fracture of the mandible. International Journal of Oral and Maxillofacial Surgery,1997,26(Suppl):239.
[15]Hachem AN, Hierl T, Schmidt S, et al. Comparison of miniplate and lag screw osteosynthesis in treatment of collum fractures. Fortschr Kiefer Gesichtschir. 1996,41:131-133.
[16]Ellis E, Reynolds ST, Park HS. A method to rigidly fixation for condylar fractures. Oral Surg Oral Oral Med Oral Pathol,1989,68(4):369-374.
[17]林野,伊彪,李自力,等,下颌骨髁突骨折轴向拉力螺钉复位固定的临床应用研究,中华口腔科杂志,1999,34(4)：245-248.
[18]张益,孙勇刚.颌骨坚固内固定.北京.北京大学医学出版社,2003：100.
[19]Ferretti C, Bryant R,Becker P, et al.Temporomandibular joint morphology following post traumatic ankylosis in 26 patients. Int J Oral Maxillofac Surg,2005, 34(4):376-381.
[20]Cascone P, Leonardi R, Marino S, et al. Intracapsular fractures of mandibular condyle:diagnosis, treatment and anatomical and pathological evaluations. Craniofac Surg,2003,14 (2):184-191.
[21]Cutright DE, Hunsuck EE. Tissue reaction to the biodegradable material, PLA.J Oral Surg,1971,29(6):393-397.
[22]Pizzoferrato A, Marchetti PG, Ravaglioli A, et al. Biomaterial and clinical application. Elsevier Science Publishers, B.V. Amsterdam.1987:439-445.
[23]Yerit KC, Enislidis G, Schopper C, et al. Fixation of mandibular fractures with biodegradable plates and screws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod,2002,94(3):294-300.
[24]杨茂进,陈渝斌.颌骨坚固内固定技术的演化.创伤外科杂志,2003：5(2)：157-159.
[25]Iizuka T, Lindqvist C, Hallikainen D, et al. Infection after rigid internal fixation of mandibular fractures:A clinical and radiologic study. J Oral Maxillofac Surg,1991, 49(6):585-593.
[26]姚军,周继林,胡敏,等.髁突纵行骨折与横断骨折的对比实验研究.中华口腔医学杂志,1999,34(3)：178-180.
[27]Joos U, Kleinheinz J. Therapy of condylar neck fractures. Int J Oral Maxillofac Surg,1998,27(4):247-254.
[28]Alpert B, Seligson D. Removal of asymptomatic bone plates used for orthognathic surgery and facial fractures.J oral Maxillofac Surg.1996:54(5):618-621.
[29]张益,章魁华.颌骨骨折坚强内固定.中华口腔医学杂志,2001,36(3)：233-235.
[30]Mosbah MR, Oloyede D, Koppel DA, et al. Mini plate removal in trauma and orthognathic surgery-a retrospective study. Int J Oral Maxillofac Surg,2003, 32(2):148-151.
[31]Matthew IR, Frame JM. Policy of consultant oral maxillofacial surgeons towards removal of miniplate components after jaw fracture fixation:pilot study. Br J Oral Maxillofac Surg,1999:37(2):110-112.
[32]郑永红,张益,孙勇刚,等.颌骨骨折坚强内固定术后取钛板原因分析.口腔颌面外科杂志,2001,11(1)：72-74.
[1]Nicholas Z, Michael M, Constintine M, et al. Fractures of the mandibular condyle: A review of 466 cases. Literature review, reflections on treatment and proposals.J Cranio-Maxillofac Surg,2006,34(7):421-432.
[2]顾晓明.口腔颌面创伤基础和临床研究三年进展.中华口腔医学杂志,2004,39(1),19-21.
[3]Schenk R, Willenegger H. Morphological findings in primary fracture healing. Symp. Biol. Hungarica,1967,8:75-86.
[4]Weinmann JP, Sicher H. Bone and Bones.St Louis:The CV Mosby Company, 1955.
[5]张益,张陈平.颌骨外科与AO内固定新进展.口腔颌面外科杂志,1999；9(4)：329.
[6]叶发刚,王本岗,王开友,等.临床骨科内固定学.北京,中国医药科技出版社,2007,7.
[7]Haug RH. Retention of asymptomatic bone plates used for orthognathic surgery and facial fractures.Oral Maxillofac Surg,1996; 54 (5):611.
[8]张骏诚,孙绍洪,鲁伟,等.钛板在颌骨骨折治疗中的临床评价.口腔颌面外科杂志,2000；10(3)：260.
[9]Righi E, Carta M, Bruzzone AA, et al. Experimental analysis of internal rigid fixation osteosynthesis performed with titanium bone screw and p late systems. J Cranio-Maxillofac Surg,1996; 24 (1):53.
[10]陈希哲.可吸收骨折内固定物及其在颌面外科的应用.国外医学口腔医学分册,1995；22(2)：65.
[11]Eppley BL, Sadove AM, Havlik RJ. Resorbale plate fixation in pediatric craniofacial surgery. Plast Reconstr Surg,1997,100 (1):1.
[12]Bostman OM, Pihlajamaki HK. Adverse tissue reactions to bioabsorbable fixation devices. Clin Orthop,2000,371:216-227.
[13]Ciccone WJ, Motz C, Bentley C, et al. Bioabsorbable implants in orthopaedics: new developments and clinical applications. J Am Acad Ortho Surg,2001,9 (5): 280.
[14]勘武生,李鹏,郑琼,等.国产可吸收螺钉的临床应用体会.骨与关节杂志,2003,18(2)：132.
[15]George K, Becker D, Seligson D, et al. Absorbable fasteners for the fixation of ankle fractures. J Ky Med Assoc.1999,97(3):105-108.
[16]Steinhauser. Zur zentralen Kiefergelenksluxation in die mittlere Schadelgrube an Hand eines Falles. Dtsch Zahn Mund Kieferheilkunde,1964.
[17]张海钟,柳春明,步荣发,等.口腔入路髁突颈及下颌支骨折复位内固定术.中华创伤杂志,2005,21(9)：641-645.
[18]郑民华,林言箴.微创外科在普外科中的应用与展望.上海口腔医学,2002,2(7)：385-388.
[19]Jacbovicz J, Lee C, Trabulsy PP. Endoscopic repair of mandibular subcondylar fractures. J Plast Reconstr Surg,1998,101(2):437-441.
[20]Lauer G, Chmelzeisen R. Endoscope-assisted fixation of mandibular condylar process fractures. J Oral Maxillofac Surg,1999,57(1):36-39.
[21]Honda T, Nozaki M, Isono N, et al. Endoscope-assisted facial fracture repair. World J Surg,2001,25(8):1075-1083.
[22]Schon R, Gutwald R, Schramm A,et al. Endoscopy-assisted open treatment of condylar fractures of the mandible:extraorat VS intraoral approach. Int J Oral Maxillofac Surg,2002,31(3):237-243.
[2]Williams JG, Cawood JL. Effects of inter maxillary fixation on pulmonary function. Int J Oral Maxillofac Surg,1990,19(2):76-78.
[3]Schilli W, Luhr HG. Rigid internal fixation by means of compression plates. Oral and Maxillofacial Traumatology, Kruger E, Schilli. Chicago, Quintessence, 1982:195-196.
[4]李冬仙,张印斗,柳新华.髁状突骨折治疗效果的临床分析.口腔医学纵横,2001,17(4)：316.
[5]Palmieri C, Ellis E, Throckmorton G. Mandibular nation after closed and open treatment of unilateral mandibular condglar process fractures. J Oral Maxillofac Surg,1999,57(6):764.
[6]Silvennoinen U, Raustia AM, Lindqvist C, et al. Occlusal and temporomandibular joint disorders in patients with unilateral condylar fracture. A prospective one year study. Int J Oral Maxillofac Surg,1998,27(4):280-285.
[7]张益,张陈平.颌骨外科与AO内固定新进展-颌骨骨折治疗.口腔颌面外科杂志,2000,10(1)：41-43.
[8]Champy M, Lodde JP, Jaeger JH, et al. Mandibular osteosynthesis according to the Michelet technique. I. Biomechanical bases. Rev Stomatol Chir Maxlillofac,1976, 77(3):569-576.
[9]张益,张兴文.髁状突骨折解剖复位及小接骨板坚固内固定.中华口腔医学杂志.2001,36(2)：99-101.
[10]张志光,许跃,何一青,等.髁状突颈部骨折手术疗法和保守疗法近期疗效评价.现代口腔医学杂志；2001,15(5)：384-38.
[11]Choi B, Kim K, Kim H, et al. An in vitro evaluation of condylar neek fraeture plating techniques. Int J Oral Maxillofac Surg.1999,28(Suppl):78-81.
[12]Ellis E. Treatment methods for fractures of the mandibular angle. Int J oral Maxillofac Surg.1999:28(4):243-252.
[13]Brons R, Boering G. Fractures of the mandibular body treated by stable internal fixation:A preliminary report. J oral Surg.1970,28(6):407-415.
[14]Teranobu O, Yamada K, Eida K, et al. Evaluation of lag screw osteosynthesis for condylar process fracture of the mandible. International Journal of Oral and Maxillofacial Surgery,1997,26(Suppl):239.
[15]Hachem AN, Hierl T, Schmidt S, et al. Comparison of miniplate and lag screw osteosynthesis in treatment of collum fractures. Fortschr Kiefer Gesichtschir. 1996,41:131-133.
[16]Ellis E, Reynolds ST, Park HS. A method to rigidly fixation for condylar fractures. Oral Surg Oral Oral Med Oral Pathol,1989,68(4):369-374.
[17]林野,伊彪,李自力,等,下颌骨髁突骨折轴向拉力螺钉复位固定的临床应用研究,中华口腔科杂志,1999,34(4)：245-248.
[18]张益,孙勇刚.颌骨坚固内固定.北京.北京大学医学出版社,2003：100.
[19]Ferretti C, Bryant R,Becker P, et al.Temporomandibular joint morphology following post traumatic ankylosis in 26 patients. Int J Oral Maxillofac Surg,2005, 34(4):376-381.
[20]Cascone P, Leonardi R, Marino S, et al. Intracapsular fractures of mandibular condyle:diagnosis, treatment and anatomical and pathological evaluations. Craniofac Surg,2003,14 (2):184-191.
[21]Cutright DE, Hunsuck EE. Tissue reaction to the biodegradable material, PLA.J Oral Surg,1971,29(6):393-397.
[22]Pizzoferrato A, Marchetti PG, Ravaglioli A, et al. Biomaterial and clinical application. Elsevier Science Publishers, B.V. Amsterdam.1987:439-445.
[23]Yerit KC, Enislidis G, Schopper C, et al. Fixation of mandibular fractures with biodegradable plates and screws. Oral Surg Oral Med Oral Pathol Oral Radiol Endod,2002,94(3):294-300.
[24]杨茂进,陈渝斌.颌骨坚固内固定技术的演化.创伤外科杂志,2003：5(2)：157-159.
[25]Iizuka T, Lindqvist C, Hallikainen D, et al. Infection after rigid internal fixation of mandibular fractures:A clinical and radiologic study. J Oral Maxillofac Surg,1991, 49(6):585-593.
[26]姚军,周继林,胡敏,等.髁突纵行骨折与横断骨折的对比实验研究.中华口腔医学杂志,1999,34(3)：178-180.
[27]Joos U, Kleinheinz J. Therapy of condylar neck fractures. Int J Oral Maxillofac Surg,1998,27(4):247-254.
[28]Alpert B, Seligson D. Removal of asymptomatic bone plates used for orthognathic surgery and facial fractures.J oral Maxillofac Surg.1996:54(5):618-621.
[29]张益,章魁华.颌骨骨折坚强内固定.中华口腔医学杂志,2001,36(3)：233-235.
[30]Mosbah MR, Oloyede D, Koppel DA, et al. Mini plate removal in trauma and orthognathic surgery-a retrospective study. Int J Oral Maxillofac Surg,2003, 32(2):148-151.
[31]Matthew IR, Frame JM. Policy of consultant oral maxillofacial surgeons towards removal of miniplate components after jaw fracture fixation:pilot study. Br J Oral Maxillofac Surg,1999:37(2):110-112.
[32]郑永红,张益,孙勇刚,等.颌骨骨折坚强内固定术后取钛板原因分析.口腔颌面外科杂志,2001,11(1)：72-74.
[1]Nicholas Z, Michael M, Constintine M, et al. Fractures of the mandibular condyle: A review of 466 cases. Literature review, reflections on treatment and proposals.J Cranio-Maxillofac Surg,2006,34(7):421-432.
[2]顾晓明.口腔颌面创伤基础和临床研究三年进展.中华口腔医学杂志,2004,39(1),19-21.
[3]Schenk R, Willenegger H. Morphological findings in primary fracture healing. Symp. Biol. Hungarica,1967,8:75-86.
[4]Weinmann JP, Sicher H. Bone and Bones.St Louis:The CV Mosby Company, 1955.
[5]张益,张陈平.颌骨外科与AO内固定新进展.口腔颌面外科杂志,1999；9(4)：329.
[6]叶发刚,王本岗,王开友,等.临床骨科内固定学.北京,中国医药科技出版社,2007,7.
[7]Haug RH. Retention of asymptomatic bone plates used for orthognathic surgery and facial fractures.Oral Maxillofac Surg,1996; 54 (5):611.
[8]张骏诚,孙绍洪,鲁伟,等.钛板在颌骨骨折治疗中的临床评价.口腔颌面外科杂志,2000；10(3)：260.
[9]Righi E, Carta M, Bruzzone AA, et al. Experimental analysis of internal rigid fixation osteosynthesis performed with titanium bone screw and p late systems. J Cranio-Maxillofac Surg,1996; 24 (1):53.
[10]陈希哲.可吸收骨折内固定物及其在颌面外科的应用.国外医学口腔医学分册,1995；22(2)：65.
[11]Eppley BL, Sadove AM, Havlik RJ. Resorbale plate fixation in pediatric craniofacial surgery. Plast Reconstr Surg,1997,100 (1):1.
[12]Bostman OM, Pihlajamaki HK. Adverse tissue reactions to bioabsorbable fixation devices. Clin Orthop,2000,371:216-227.
[13]Ciccone WJ, Motz C, Bentley C, et al. Bioabsorbable implants in orthopaedics: new developments and clinical applications. J Am Acad Ortho Surg,2001,9 (5): 280.
[14]勘武生,李鹏,郑琼,等.国产可吸收螺钉的临床应用体会.骨与关节杂志,2003,18(2)：132.
[15]George K, Becker D, Seligson D, et al. Absorbable fasteners for the fixation of ankle fractures. J Ky Med Assoc.1999,97(3):105-108.
[16]Steinhauser. Zur zentralen Kiefergelenksluxation in die mittlere Schadelgrube an Hand eines Falles. Dtsch Zahn Mund Kieferheilkunde,1964.
[17]张海钟,柳春明,步荣发,等.口腔入路髁突颈及下颌支骨折复位内固定术.中华创伤杂志,2005,21(9)：641-645.
[18]郑民华,林言箴.微创外科在普外科中的应用与展望.上海口腔医学,2002,2(7)：385-388.
[19]Jacbovicz J, Lee C, Trabulsy PP. Endoscopic repair of mandibular subcondylar fractures. J Plast Reconstr Surg,1998,101(2):437-441.
[20]Lauer G, Chmelzeisen R. Endoscope-assisted fixation of mandibular condylar process fractures. J Oral Maxillofac Surg,1999,57(1):36-39.
[21]Honda T, Nozaki M, Isono N, et al. Endoscope-assisted facial fracture repair. World J Surg,2001,25(8):1075-1083.
[22]Schon R, Gutwald R, Schramm A,et al. Endoscopy-assisted open treatment of condylar fractures of the mandible:extraorat VS intraoral approach. Int J Oral Maxillofac Surg,2002,31(3):237-243.