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Проблемы стоматологии Actual problems in dentistry
2019, том 15, № 2, стр. 46—49 Хирургическая стоматология / Оригинальные исследования 2019, vol. 15, № 2, pp. 46— 49
© 2019, Екатеринбург, УГМУ Surgical dentistry / Original research papers © 2019, Ekaterinburg, USMU
DOI: 10.18481/2077-7566-2019-15-2-46-49 УДК: 617.52; 617.76
ЭПИДЕМИОЛОГИЯ ПЕРЕЛОМОВ СТЕНОК ОРБИТ. РЕТРОСПЕКТИВНОЕ ИССЛЕДОВАНИЕ
Абдулкеримов Т.Х.1, Мандра Ю.В.1, Герасименко В.И.1, Цех Д.В.2, Саматов Н.Р.2, Мандра Е.В.3, Жегалина Н.М.1, Епишова А.А.1
1 ФГБОУ ВО «Уральский государственный медицинский университет» Минздрава России, г. Екатеринбург, Россия
2 Центральная городская клиническая больница № 23, г. Екатеринбург, Россия
3 Сеченовский университет, г. Москва, Россия
Аннотация
Переломы костей средней зоны лицевого скелета представлены множеством различных вариантов конфигурации зоны повреждения, а также различной степенью их тяжести. Переломы стенок орбит в структуре травматических повреждений краниофациальной зоны занимают особое место. В настоящее время существуют две основные теории возникновения данных переломов: Blow-out и Force transmission. Согласно первой, перелом стенок глазницы происходит при резком повышении интраорбитального давления, согласно второй, в основе механизма перелома лежит передача приложенной силы через наружные края глазницы непосредственно на более хрупкие ее стенки. Кроме того, у лиц молодого возраста в силу особенностей анатомического строения костной ткани, актуален механизм перелома стенок орбиты по типу «закрытой дверцы» (Trapdoor), когда происходит перелом без формирования костного дефекта, но содержимое глазницы пролабирует в щель перелома, где происходит его ущемление. Нередко в зону ущемления попадает и нижняя прямая мышца глаза, что является достаточно грозным осложнением.
По данным зарубежных авторов, переломы наружных краев и стенок глазниц встречаются более чем в 40 % всех случаев травм костей лицевого скелета. По данным отечественных авторов, частота переломов скулоорбитального комплекса и верхней челюсти составляет 12 и 8 % соответственно. Кроме того, сложность строения глазницы, а также близость расположения органа зрения могут вызвать определенные трудности как в диагностике, так и лечении данных пациентов.
В статье рассмотрены вопросы особенностей анатомического строения глазниц, а также эпидемиологии орбитальной травмы на основании статистических данных нейрохирургического отделения ЦГКБ № 23 г. Екатеринбурга за 2017 год.
Ключевые слова: орбита, реконструктивная хирургия, перелом, черепно-челюстно-лицевая хирургия, сочетанная травма
Авторы заявляют об отсутствии конфликта интересов The authors declare no conflict of interes
Адрес для переписки:
Тимур Хийирович АБДУЛКЕРИМОВ
620109, г. Екатеринбург, ул. Анри Барбюса, д. 6, кв. 49
Тел.: +79126707006
tabdulkerimov05@gmail.com
Образец цитирования:
Correspondence address:
Timur Kh. ABDULKERIMOV
620109, Anri barbyusa str., 6-49, Ekaterinburg, Russia Pfone: +79126707006 tabdulkerimov05@gmail.com
For citation:
Абдулкеримов Т.Х., Мандра Ю.В., Герасименко В.И., Цех Д.В.,
Саматов Н.Р., Мандра Е.В., Жегалина Н.М., Епишова А.А.
ЭПИДЕМИОЛОГИЯ ПЕРЕЛОМОВ СТЕНОК ОРБИТ.
РЕТРОСПЕКТИВНОЕ ИССЛЕДОВАНИЕ
Проблемы стоматологии, 2019, т. 15, № 2, стр. 46— 49
© Абдулкеримов Т.Х. и др. 2019
DOI: 10.18481/2077-7566-2019-15-2-46-49
Abdulkerimov T.Kh., Mandra J.V., Gerasimenko V.I., Tsekh D.V., Samatov N.R., Mandra E.V., Zhegalina N.M., Yepishova A.A. FREQUENCY OF THE ORBITAL WALLS FRACTURES. A RETROSPECTIVE STUDY
Actual problems in dentistry, 2019, vol. 15, № 2, pp. 46— 49
© Abdulkerimov T.Kh. al. 2019
DOI: 10.18481/2077-7566-2019-15-2-46-49
DOI: 10.18481/2077-7566-2019-15-2-46-49
FREQUENCY OF THE ORBITAL WALLS FRACTURES. A RETROSPECTIVE STUDY
Abdulkerimov T.Kh.1, Mandra J.V.1, Gerasimenko V.I.1, Tsekh D.V.2, Samatov N.R.2, Mandra E.V.3, Zhegalina N.M.1, Yepishova A.A.1
1 Ural state medical university, Ekaterinburg, Russia
2 Central City Clinical Hospital No. 23, Ekaterinburg, Russia
3 Sechenov University, Moscow, Russia
Summary
Midfacial fractures are presented by wide range of different patterns and severity. Orbital walls fractures have a special place in the structure of traumatic craniofacial injuries. Referring foreign authors, fractures of external rims and internal orbital walls are presented in more than 40 % of all bony injuries of facial skeleton. And referring Russian authors frequency of zygomaticomaxillary complex and isolated maxillary fractures presented by 12 and 8 % respectively. Furthermore complex anatomy of the orbit and proximity of the globe can occur some difficulties in diagnostics and treatment process of these patients. Today there are two main mechanisms of orbital walls fractures development - Blow-out, when fracture caused by increasing of intraorbital pressure, and Force-transmission, when force applied to external orbital rims transmits to a weaker orbital walls. Moreover in young patients Trapdoor mechanism is actual, which results in entrapment of soft tissues in the fracture line. Often there is an inferior rectus muscle entrapment and that is serious complication, when immediate surgery is required.
The article deals with issues of anatomical construction of orbit and orbital trauma epidemiology based on statistics of neurosurgical department of Central city clinical hospital № 23, Ekaterinburg, for 2017.
Keywords: orbit, reconstructive surgery, fracture, craniomaxillofacial surgery, combined trauma
Introduction
Midfacial fractures are quite often for patients with fractures of the facial skeleton. K. Kunz reports, that in more than 40 % of facial fractures orbital rims or internal orbital walls are involved showing different fracture patterns [2]. Injuries of zygomatico-maxillary and naso-orbito-ethmoidal complexes and their combinations demonstrates great variety between orbital fractures from simple ones to more difficult comminuted [1, 13]. In simple cases single-wall "blow-out" fractures are common and more frequent. Nevertheless, surgeon should remember that the orbit is complex 3D-structure and need extra-precision in reconstruction [5, 6, 8, 10, 11, 14].
Theory
Due to anatomic features of bony orbit, frequency of orbital fractures is differ between its regions. Orbit is presented as pyramidal cavity, formed by 7 different bones [10]:
• lateral wall presented by greater wing of sphenoid bone and orbital surface of zygomatic bone. Both of them are quite massive and any fracture of lateral orbital wall will be accompanied with injury of zygomatic component [12, 17, 21];
• medial wall consists of lacrimal bone and orbital plate of ethmoidal bone called "lamina papyracea" because of its small thikness;
• lower wall (orbital floor) presented by orbital surface of maxilla and orbital process of palatal bone in distal portion [2]. Orbital floor is quite fragile structure, which don't have any reinforcements by complex bony parts as medial wall for example, what explains prevalence of orbital floor fractures over other ones [4];
• upper wall (orbital roof) formed by orbital surface of frontal bone and lesser wing of sphenoid bone in distal parts;
• apical part of orbit is the point of exit of the optical nerve and phylogenetically presented as massive structure, formed by lesser wing of sphenoid bone. Between forming parts of orbit there are several
important anatomical spaces:
• between lateral and upper walls there is upper orbital fissure which connecting orbital cavity with middle cranial fossa;
• there is lower orbital fossa located on a border between orbital floor and lateral wall, connecting orbital cavity with pterygopalatine fossa and subtemporal fossa [22, 19].
S-shape of orbital floor is the key-factor of globe positioning in orbital cavity and it's very important to restore orbital volume to avoid the globe dislocation (fig. 1), also surgeon during the orbital floor reconstruction must remember that's there is an infraorbital nerve near it [16, 18, 20, 23—25];
• external orbital rims are massive structures consists of frontal, zygonamic bones and maxilla, and it's strategically important point for comminuted fractures reconstruction [3, 9].
Due to the anatomical features, functional and aesthetic significance of this area, fractures of the midface, especially orbital fractures, epidemiology of traumatic injuries in this localization has special interest [4, 7, 9, 15].
Data and methods
We are performed a retrospective analysis of medical documentation of 190 patients males and females aged from 18 to 65 years old with isolated and concominant injuries of cranio-maxillofacial region, hospitalized in neurosurgical department of Central City Clinical Hospital № 23 in Ekaterinburg city. Received data was statistically processed using Microsoft Office Excell 2010 software.
Проблемы стоматологии
2019, том 15, № 2, стр. 46—49 Хирургическая стоматология / Оригинальные исследования
© 2019, Екатеринбург, УГМУ Surgical dentistry / Original research papers
Table
Fig. 1. S-shape of orbital floor (sagittal slice) Рис. 1. С-образная форма нижней стенки орбиты (сагиттальный срез)
Fig. 2. Total post-traumatic defect of orbital floor Рис. 2. Тотальный посттравматический дефект нижней стенки орбиты
Results
During the study, a retrospective analysis of medical documentation of 190 male and female patients aged from 18 to 65 years old who were hospitalized and treated at the neurosurgical department of the Central City Clinical Hospital № 23 with isolated and combined traumatic injuries of the facial skeleton, especially with orbital injuries, was performed for the period from 01.01.2017 to 12.31.2017.
The sample is presented by patients with isolated fractures of the orbital floor, medial wall, combined fractures of the orbital floor and zygomatico-maxillary complex, orbital walls and anterior cranial fossa, fractures of orbital walls and maxilla/mandible. The results of the study are presented in table.
From the obtained results follows, that the most frequent variant of orbital injury is an isolated orbital
Frequency of isolated and combined orbital fractures Табл. Частота встречаемости изолированных и сочетанных переломов стенок орбит
Fracture localization Quantity of patients
Orbital floor 68
Medial orbital wall 19
Orbital floor and zygomatico-maxillary complex 59
Orbital walls and mandible 20
Orbital walls and maxilla 20
Orbital walls and anterior cranial fossa 4
floor fracture (68 cases, fig. 2), as well as a combination of orbital floor fracture with the zygomatico-maxillary complex (59 cases). Combined fractures of orbital walls and anterior cranial fossa (4 cases) were less frequent.
Conclusion
1. Considering the features of the orbital anatomy, as well as the aesthetic significance of this area, the correct and well-timed surgery of orbital fractures have a great importance in the comprehensive rehabilitation of patients with traumatic injuries of the facial skeleton.
2. According recieved data from retrospective study, isolated orbital floor fractures, as well as a combination of orbital floor and zygomatico-maxillary complex fractures are the most frequent.
3. Less frequency showed by combined fractures of orbital walls and anterior cranial fossa.
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13. Park, M. S. Measurement of fracture size using the picture archiving communication system in an outpatient clinic for factors that influence postoperative enophthalmos in adult inferior orbital wall fractures / M. S. Park, S. Baek // J Craniofac Surg. - 2013. - Vol. 24 (5). - P. 1692-1694.
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16. Ord, R. A. Acute retrobulbar hemorrhage complicating a malar fracture / R. Ord, A. el-Attar // J Oral Maxillofac Surg. - 1982. - Vol. 40 (4). - P. 234-236.
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19. Potter, J. K. Biomaterials for reconstruction of the internal orbit / J. K. Potter, M. Malmquist, E. Ellis // Oral Maxillofac Surg Clin North Am. - 2012. - Vol. 24 (4). - P. 609-627.
20. Correction of severe enophthalmos by simultaneous fat grafting and anatomic orbital reconstruction / P. Metzler, H. H. Ezaldein, M. J. Pfaff [et al.] // J Craniofac Surg. -
2014. - Vol. 25 (5). - P. 1829-1832.
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25. Hess area ratio and diplopia: evaluation of 30 patients undergoing surgical repair for orbital blow-out fracture / P. L. Grenga, G. Reale, C. Cofone [et al.] // Ophthal Plast Reconstr Surg. - 2009. - Vol. 25 (2). - P. 123-125.
References
1. Kulakov, A. A., Robustova, T. G., Nerobeev, A. I. (2010). Khirurgicheskaya stomatologiya i chelyustno-litsevaya khirurgiya: natsional'noye rukovodstvo [Surgical dentistry and Maxillofacial surgery: national guidance]. Moscow: GEOTAR-Media, 928. (In Russ.)
2. Ehrenfeld, M., Manson, P., Prein, J. (2012). Principles of internal fixation of the Craniomaxillofacial skeleton. Trauma and orthognathic surgery. Zurich: Thieme, 395.
3. Brennan, P., Ghali, G. E., Cascarini, L. (2017). Maxillofacial surgery, 3-rd edition. - St. Louis: Elsevier, 1562.
4. Neinstein, R. M., Phillips, J. H., Forrest, C. R. (2012). Pediatric orbital floor trapdoor fractures: outcomes and CT-based morphologic assessment of the inferior rectus muscle. J Plast Reconstr Aesthet Surg, 65 (7), 869-874.
5. Ord, R. A., el-Attar, A. (1982). Acute retrobulbar hemorrhage complicating a malar fracture. J OralMaxillofac Surg, 40 (4), 234-236.
6. Biomechanical mechanisms of orbital wall fractures—a transient finite element analysis / A. Schaller, H. Huempfner-Hierl, A. Hemprich [et al.] // J Craniomaxillofac Surg. -2013. - Vol 41 (8). - P. 710-717.
7. Cobb, A. R., Jeelani, N. O., Ayliffe, P. R. (2013). Orbital fractures in children. Br J Oral Maxillofac Surg, 51 (1), 41^6.
8. Bite, U., Jackson, I. T., Forbes, G. S. et al. (1985). Orbital volume measurements in enophthalmos using three-dimensional CT imaging. Plast Reconstr Surg, 75 (4), 502-508.
9. Brisco, J., Fuller, K., Lee, N. et al. (2014). Cone beam computed tomography for imaging orbital trauma—image quality and radiation dose compared with conventional multislice computed tomography. Br J Oral Maxillofac Surg, 52 (1), 76-80.
10.Ahmad, F., Kirkpatrick, N. A., Lyne, J. et al. (2006). Buckling and hydraulic mechanisms in orbital blowout fractures: fact or fiction? J Craniofac Surg, 17 (3), 438^-41.
11. Dutton, G. N., al-Qurainy, I., Stassen, L. F. et al. (1992). Ophthalmic consequences of mid-facial trauma. Eye (Lond), 6, 1, 86-89.
12. Evans, B. T., Webb, A. A. (2007). Post-traumatic orbital reconstruction: anatomical landmarks and the concept of the deep orbit. Br J Oral Maxillofac Surg, 45 (3), 183-189.
13. Park, M. S., Baek, S. (2013). Measurement of fracture size using the picture archiving communication system in an outpatient clinic for factors that influence postoperative enophthalmos in adult inferior orbital wall fractures. J Craniofac Surg, 24 (5), 1692-1694.
14. Key, S. J., Ryba, F., Holmes, S., et al. (2008). Orbital emphysema—the need for surgical intervention. J Craniomaxillofac Surg, 36 (8), 473^-76.
15. Neinstein, R. M., Phillips, J. H., Forrest, C. R. (2012). Pediatric orbital floor trapdoor fractures: outcomes and CT-based morphologic assessment of the inferior rectus muscle. J Plast Reconstr Aesthet Surg, 65 (7), 869-874.
16. Ord, R.A., el-Attar, A. (1982). Acute retrobulbar hemorrhage complicating a malar fracture. J Oral Maxillofac Surg, 40 (4), 234-236.
17. Ilankovan, V. (1991). Transconjunctival approach to the infraorbital region: a cadaveric and clinical study. Br J Oral Maxillofac Surg, 29 (3), 169-172.
18. Sleep, T. J., Evans, B. T., Webb, A. A. (2007). Resolution of diplopia after repair of the deep orbit. Br J Oral Maxillofac Surg, 45 (3), 190-196.
19. Potter, J. K., Malmquist, M., Ellis, E. (2012). Biomaterials for reconstruction of the internal orbit. Oral Maxillofac Surg Clin North Am, 24 (4), 609-627.
20. Metzler, P., Ezaldein, H. H., Pfaff, M. J. et al. (2014). Correction of severe enophthalmos by simultaneous fat grafting and anatomic orbital reconstruction. J Craniofac Surg, 25 (5), 1829-1832.
21. Metzger, M. C., Schen, R., Tetzlaf, R. et al. (2007). Topographical CT-data analysis of the human orbital floor. Int J Oral Maxillofac Surg, 36 (1), 45-53.
22. McClenaghan, F. C., Ezra, D. G., Holmes, S. B. (2011). Mechanisms and management of vision loss following orbital and facial trauma. Curr Opin Ophthalmol, 22 (5), 426^31.
23. Kim, Y. K., Park, C. S., Kim, H. K., et al. Correlation between changes of medial rectus muscle section and enophthalmos in patients with medial orbital wall fracture. J Plast Reconstr Aesthet Surg, 62 (11), 1379-1383.
24. He, D., Li, Z., Shi, W., et al. (2012). Orbitozygomatic fractures with enophthalmos: analysis of 64 cases treated late. J Oral Maxillofac Surg, 70 (3), 562-576.
25. Grenga, P. L., Reale, G., Cofone, C. et al. (2009). Hess area ratio and diplopia: evaluation of 30 patients undergoing surgical repair for orbital blow-out fracture. Ophthal Plast Reconstr Surg, 25 (2), 123-125.
Авторы:
Тимур Хийирович АБДУЛКЕРИМОВ
врач — челюстно-лицевой хирург, аспирант кафедры терапевтической стоматологии и пропедевтики стоматологических заболеваний, Уральский государственный медицинский университет, г. Екатеринбург, Россия tabdulkerimov05@gmail.com Юлия Владимировна МАНДРА
д. м. н., профессор кафедры терапевтической стоматологии и пропедевтики стоматологических заболеваний, Уральский государственный медицинский университет, г. Екатеринбург jmandra@mail.ru
Владислав Игоревич ГЕРАСИМЕНКО
врач-нейрохирург, ассистент кафедры нервных болезней, нейрохирургии и медицинской генетики, Уральский государственный медицинский университет, г. Екатеринбург, Россия vlad.gerasimenko75@mail.ru Дмитрий Викторович ЦЕХ
врач-нейрохирург, Центральная городская клиническая больница № 23, г. Екатеринбург, Россия neurosurgery-23@mail.ru Никита Равильевич САМАТОВ
врач — челюстно-лицевой хирург, Центральная городская клиническая больница № 23, г. Екатеринбург, Россия nikitasamatov@yandex.ru Екатерина Владимировна МАНДРА
Сеченовский университет, студентка 4 курса ЛПФ, Москва, Россия
emandra97@mail.ru
Наталья Максовна ЖЕГАЛИНА
к.м.н., доцент кафедры терапевтической стоматологии и пропедевтики стоматологических заболеваний Уральского государственного медицинского университета Минздрава России, Екатеринбург, Россия nzhegalina@mail.ru Анна Андреевна ЕпИшОВА
к.м.н., доцент кафедры терапевтической стоматологии и пропедевтики стоматологических заболеваний Уральского государственного медицинского университета Минздрава России, Екатеринбург, Россия yepichova9@mail.ru
Authors:
Timur Kh. ABDULKERIMOV
Oral & maxillofacial surgeon, PhD student oof the department oof therapeutic dentistry and propedeutics oof dental diseases oof the Ural State Medical Universit, Ekaterinburg, Russia tabdulkerimov05@gmail.com Julia V. MANDRA
Doctor of Medical Sciences, Professor oof the Department oof Therapeutic Dentistry and Propedeutics of Dental Diseases of the Ural State Medical University, Ekaterinburg jmandra@mail.ru Vladislav I. GERASIMENKO
Neurosurgeon, assistant at the Department of Nervous Diseases, Neurosurgery and Medical Genetics, Ural State Medical University, Ekaterinburg, Russia vlad.gerasimenko75@mail.ru Dmitry V. TSEKH
Neurosurgeon, Central City Clinical Hospital No. 23, Ekaterinburg
neurosurgery-23@mail.ru
Nikita R. SAMATOV
Oral & maxillofacial surgeon, Central City Clinical Hospital No. 23, Ekaterinburg, Russia nikitasamatov@yandex.ru Ekaterina V. MANDRA
4th year student oof the Therapeutic-prophylactic faculty oof the Sechenov University, Moscow, Russia emandra97@mail.ru Natalia M. ZHEGALINA
PhD, Associate Professor oof the Department oof Therapeutic Dentistry and Propedeutics oof Dental Diseases oof the Ural State Medical University oof the Ministry of Health of Russia, Ekaterinburg, Russia nzhegalina@mail.ru Anna A. YEPISHOVA
PhD, Associate Professor of the Department of Therapeutic Dentistry and Propedeutics oof Dental Diseases oof the Ural State Medical University oof the Ministry of Health of Russia, Ekaterinburg, Russia yepichova9@mail.ru
Поступила 20.06.2019 Received
Принята к печати 12.07.2019 Accepted
