面中部骨折坚强内固定的临床研究
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摘要
目的:探讨坚强内固定技术在面中部骨折治疗中的应用,为面中部骨折坚强内固定治疗提供理论依据和临床指导。
方法:选择天津医科大学总医院口腔颌面外科1991-2006年间应用小型和微型钛板坚强内固定方法治疗的220例面中部骨折患者为研究对象,对该组病例进行总结,包括年龄、性别、致伤原因、骨折部位、合并伤、手术入路、钛板放置、颌间固定、术后咬合关系、并发症等情况,将结果输入excel数据库,以统计图表的形式表示汇总后所得的结果,对相关数据进行统计学处理并进行论述。
结果:220例患者中以上颌骨骨折最为常见,占全部骨折的39.09%。最易伴发的合并伤为下颌骨骨折。在手术入路上,本组病例中前庭沟切口应用最为广泛,占32.73%,其次为口内外联合切口,占32.27%。在钛板放置位置上,主要固定于:颧牙槽嵴、颧额缝(眶外缘)、眶下缘、颧弓、梨状孔旁等支柱部位。钛板应用上,应用微型钛板351块,小型钛板267块,二者之比:1.31:1。上颌骨骨折应用小型钛板较多,占68.29%,而颧骨颧弓骨折、颧骨复合体骨折、眼眶及鼻眶筛骨折则较多应用微型钛板。104例患者术后给予颌间牵引固定,占47.27%,新鲜骨折组和陈旧骨折组之间、伴下颌骨骨折组和不伴下颌骨骨折组之间、上颌骨骨折组和颧骨复合体骨折组之间的颌间牵引率均存在统计学差异(P＜0.05);在坚强内固定术后颌关系恢复方面,新鲜骨折组和陈旧骨折组在术后4周存在统计学差异(P＜0.05);伴下颌骨骨折组和不伴下颌骨骨折组术后当天和术后4周均存在统计学差异(P＜0.05);术后4周,202例患者开口度大于2cm,其中,99例患者开口度大于3cm,在未行颌间固定组,60.34%的病例术后开口度正常,在颌间固定组,只有27.88%的病例术后4周开口度正常。感染是面中部骨折坚强内固定术后的常见并发症,不同钛板数量术后感染率存在统计学差异(P＜0.05),应用3-7块钛板者更易发生感染。面中部骨折坚强内固定术后并发症还包括眶下神经损伤、咬合干扰等。218例患者获得正常理想面型。
结论:微型或小型钛板坚强内固定适用于面中部骨折,在骨折线的对位以及术后颌关系、开口度的恢复方面均良好,小型钛板在许多位置上被微型钛板取代。对于多发性、粉碎性以及陈旧性骨折,单纯坚强内固定有时难以达到满意效果可以辅助颌间牵引固定。面中部骨折坚强内固定的手术入路以前庭沟切口及口内外联合切口常用,钛板放置以恢复垂直和水平支柱为原则。应尽量避免术后感染,减少颌干扰的发生。
Object: To discuss the application of rigid internal fixation (RIF) on midface fractures and provide the theoretical foundation and clinical guidance for the rigid internal fixation on midface fractures.
Methods: 220 patients with midface fractures treated by rigid internal fixation with titanium mini plates and titanium micro plates were chosen from the patients treated in the Department of Oral and Maxillofacial surgery, Tianjin Medical University General Hospital from 1991 to 2006. The patients were analyzed according to age, gender, cause of injury , position of fracture, accompanying systemic injuries, operative approach, setting of titanium plates,inter maxillary fixation, postoperative occlusion, postoperative complication and so on. Then, the data were input Excel database, and displayed by statistic chart. We analyzed the data and then discussed as follows.
Results: Among the 220 patients, the maxillary fracture was the most popular, at a rate of 39.09% in all, and the most of associated systemic injuries was mandibular fracture. Among this group of patients, the upper vestibule incision was used most extensively, at a rate of 32.73% in all approachs, the next approach was the combining with interoral and extraoral incision, at a rate of 32.27% in all. The titanium plates was always placed at the site of vertical and horizontal brace such as:zygoma-alveolar, zygoma-frontal brim,suborbital edge,zygomatic arch and pear-shaped aperture et al. 351 pieces of micro plate and 267 pieces of mini plates were applied in all patients In our study, the more miniplates were applied in maxillary fractures and the more microplates were applied in zygomatic, orbital, and naso-orbital-ethmoid (NOE) fractures. In this group, 104 patients were treated by intermaxillary fixation postoperatively, the rate was 42.27%. There was significant difference in the rate of intermaxillary fixation between the group of fresh fractures and staled ones, the group companying mandibular fractures and non-company ing mandibular fractures, and the group of maxillary fractures and zygomatic complex fractures, (P<0.05) .There was significant difference in the occlusion recovery between the group of fresh fractures and the staled ones by the fourth week after operation. (P<0.05) ,and by the first day and the fourth week afer operation there was significant difference between the group of companying mandibular fractures and that of non-companying mandibular fractures. By the fourth week after operation, the degree of open mouth of 202 patients was larger than 2cm,that of 99 patients was larger than 3 cm. In the group of non-intermaxillary fixation, the rate of normal degree of open mouth was 60.34%,whereas the rate was only 27.88% in the group of intermaxillary fixation. Infection was popular complication in RIF of midface fractures, there was significant difference between the group of 1 -2 pieces of plates applied and that of 3-7 pieces of plates. There was more opportunity of infection in the group of 3-7 pieces of plates applied. In addition, the complication of RIF of midface fratures also include suborbital nerve injury, occlusal interference, etc. 218 patients acqired ideal face profile.
Conclusion: RIF has the advantages over conventional intermaxillary fixation, in the stability of fracture fixation, the recovery of occlusion, the degree of open mouth and the face profile. It is essential for the fracures of multiple, comminuted and staled treated by RIF together with intermaxillary fixation to achieve perfect effect. The upper vestibule incision, the combining interoral incision with extraoral incision were the approach widely used in midface fracture. The principle should be abided that the vertical and horizontal braces were restored with the titanium plates. Infection should be avoided and occlusal interference should be reduced.
方法:选择天津医科大学总医院口腔颌面外科1991-2006年间应用小型和微型钛板坚强内固定方法治疗的220例面中部骨折患者为研究对象,对该组病例进行总结,包括年龄、性别、致伤原因、骨折部位、合并伤、手术入路、钛板放置、颌间固定、术后咬合关系、并发症等情况,将结果输入excel数据库,以统计图表的形式表示汇总后所得的结果,对相关数据进行统计学处理并进行论述。
结果:220例患者中以上颌骨骨折最为常见,占全部骨折的39.09%。最易伴发的合并伤为下颌骨骨折。在手术入路上,本组病例中前庭沟切口应用最为广泛,占32.73%,其次为口内外联合切口,占32.27%。在钛板放置位置上,主要固定于:颧牙槽嵴、颧额缝(眶外缘)、眶下缘、颧弓、梨状孔旁等支柱部位。钛板应用上,应用微型钛板351块,小型钛板267块,二者之比:1.31:1。上颌骨骨折应用小型钛板较多,占68.29%,而颧骨颧弓骨折、颧骨复合体骨折、眼眶及鼻眶筛骨折则较多应用微型钛板。104例患者术后给予颌间牵引固定,占47.27%,新鲜骨折组和陈旧骨折组之间、伴下颌骨骨折组和不伴下颌骨骨折组之间、上颌骨骨折组和颧骨复合体骨折组之间的颌间牵引率均存在统计学差异(P＜0.05);在坚强内固定术后颌关系恢复方面,新鲜骨折组和陈旧骨折组在术后4周存在统计学差异(P＜0.05);伴下颌骨骨折组和不伴下颌骨骨折组术后当天和术后4周均存在统计学差异(P＜0.05);术后4周,202例患者开口度大于2cm,其中,99例患者开口度大于3cm,在未行颌间固定组,60.34%的病例术后开口度正常,在颌间固定组,只有27.88%的病例术后4周开口度正常。感染是面中部骨折坚强内固定术后的常见并发症,不同钛板数量术后感染率存在统计学差异(P＜0.05),应用3-7块钛板者更易发生感染。面中部骨折坚强内固定术后并发症还包括眶下神经损伤、咬合干扰等。218例患者获得正常理想面型。
结论:微型或小型钛板坚强内固定适用于面中部骨折,在骨折线的对位以及术后颌关系、开口度的恢复方面均良好,小型钛板在许多位置上被微型钛板取代。对于多发性、粉碎性以及陈旧性骨折,单纯坚强内固定有时难以达到满意效果可以辅助颌间牵引固定。面中部骨折坚强内固定的手术入路以前庭沟切口及口内外联合切口常用,钛板放置以恢复垂直和水平支柱为原则。应尽量避免术后感染,减少颌干扰的发生。
Object: To discuss the application of rigid internal fixation (RIF) on midface fractures and provide the theoretical foundation and clinical guidance for the rigid internal fixation on midface fractures.
Methods: 220 patients with midface fractures treated by rigid internal fixation with titanium mini plates and titanium micro plates were chosen from the patients treated in the Department of Oral and Maxillofacial surgery, Tianjin Medical University General Hospital from 1991 to 2006. The patients were analyzed according to age, gender, cause of injury , position of fracture, accompanying systemic injuries, operative approach, setting of titanium plates,inter maxillary fixation, postoperative occlusion, postoperative complication and so on. Then, the data were input Excel database, and displayed by statistic chart. We analyzed the data and then discussed as follows.
Results: Among the 220 patients, the maxillary fracture was the most popular, at a rate of 39.09% in all, and the most of associated systemic injuries was mandibular fracture. Among this group of patients, the upper vestibule incision was used most extensively, at a rate of 32.73% in all approachs, the next approach was the combining with interoral and extraoral incision, at a rate of 32.27% in all. The titanium plates was always placed at the site of vertical and horizontal brace such as:zygoma-alveolar, zygoma-frontal brim,suborbital edge,zygomatic arch and pear-shaped aperture et al. 351 pieces of micro plate and 267 pieces of mini plates were applied in all patients In our study, the more miniplates were applied in maxillary fractures and the more microplates were applied in zygomatic, orbital, and naso-orbital-ethmoid (NOE) fractures. In this group, 104 patients were treated by intermaxillary fixation postoperatively, the rate was 42.27%. There was significant difference in the rate of intermaxillary fixation between the group of fresh fractures and staled ones, the group companying mandibular fractures and non-company ing mandibular fractures, and the group of maxillary fractures and zygomatic complex fractures, (P<0.05) .There was significant difference in the occlusion recovery between the group of fresh fractures and the staled ones by the fourth week after operation. (P<0.05) ,and by the first day and the fourth week afer operation there was significant difference between the group of companying mandibular fractures and that of non-companying mandibular fractures. By the fourth week after operation, the degree of open mouth of 202 patients was larger than 2cm,that of 99 patients was larger than 3 cm. In the group of non-intermaxillary fixation, the rate of normal degree of open mouth was 60.34%,whereas the rate was only 27.88% in the group of intermaxillary fixation. Infection was popular complication in RIF of midface fractures, there was significant difference between the group of 1 -2 pieces of plates applied and that of 3-7 pieces of plates. There was more opportunity of infection in the group of 3-7 pieces of plates applied. In addition, the complication of RIF of midface fratures also include suborbital nerve injury, occlusal interference, etc. 218 patients acqired ideal face profile.
Conclusion: RIF has the advantages over conventional intermaxillary fixation, in the stability of fracture fixation, the recovery of occlusion, the degree of open mouth and the face profile. It is essential for the fracures of multiple, comminuted and staled treated by RIF together with intermaxillary fixation to achieve perfect effect. The upper vestibule incision, the combining interoral incision with extraoral incision were the approach widely used in midface fracture. The principle should be abided that the vertical and horizontal braces were restored with the titanium plates. Infection should be avoided and occlusal interference should be reduced.
引文
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