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Prospects for use of resorbable membrane made of polylactic acid in the treatment of mandibular fractures
Трудности диагностики экстраоссальной саркомы Юинга возникают из-за её сходства в строении с другими злокачественными новообразованиями мягких тканей (нейробластома, синовиальная саркома, злокачественная лимфома, рабдиосаркома, ангиоперицитома, низкодифференцированный рак), которые, несмотря
на различный гистогенез, не имеют специфических морфологических признаков. Поэтому для постановки окончательного диагноза патоморфологическое исследование данной опухоли необходимо дополнять иммуногистохимическим и молекулярно-биологическим методами исследования.
Список литературы:
1. Порошин К. К., Галил-Оглы Г. А. Внескелетная локализация саркомы Юинга./К.К Порошин, Г. А. Галил-Оглы//Архив патологии. - 1980. - № 9. - С. 58-61.
2. Мария Яллурос, Штефани Кульбе. Саркомы мягких тканей и редкие мягкотканные опухоли. [Электронный ресурс], - http://www.kinderkrebsinfo.de
3. Смольянников А. В. Опухоли и опухолеподобные поражения мягких тканей. В кн. Руководство. Патолого-анатомическая диагностика опухолей человека. - М.: Изд-во «Медицина». С. 366.
4. Противораковое общество России/саркома Юинга у детей. [Электронный ресурс], - http://www. pror.ru/forms_kids_ewing.shtml.
5. Соловьёв Ю. Н. Новый взгляд на природу опухоли Юинга./Ю. Н. Соловьёв//Вестник РОНЦ им. Блохина РАМН. - 1995. - № 1. - С. 3-6.
6. Семёнова А. И. Саркома Юинга и примитивные нейроэктодермальные опухоли /А. И. Семёнова //Практическая онкология. - 2005. - 6 (4). - С. 234-239.
7. Мишнев О. Д., Дубова Е. А., Пикунов М. Ю., Щеголев А. И., Кармазановский Г. Г. Внекостная саркома Юинга грудной стенки./О. Д. Мишнев, Е. А. Дубова, М. Ю. Пикунов, А. И. Щеголев, Г. Г. Кармазановский//Медицинская визуализация. - 2009. - № 1. - С. 83-88.
Idashkina Natalya, PhD, SE «Dnipropetrovsk medical academy Ministry of Health of Ukraine», Oral surgery, implantology and periodontology department, Dnipropetrovsk, Ukraine
E-mail: idashkina@ukr.net
Prospects for use of resorbable membrane made of polylactic acid in the treatment of mandibular fractures
Abstract: The method of intraoral polymer osteosynthesis with the use of resorbable polylactic acid membranes for fixation ofbone fragments in treatment of the simple or complicated mandibular fractures is offered. Clinical and roentgenological researches confirmed its efficiency owing to atraumatic and reliable fixation during all period of treatment, that is promote the anatomic and physiologic rehabilitation in the optimum terms.
Keywords: fractures of the mandible, complication, polylactic acid membranes, polymer osteosynthesis.
The reduction in the frequency ofcomplicationsin to select imperfection of surgical treatment as reason the treatment of mandibular fractures is the urgent causes development of complications. The most task of modern maxillofacial surgery. It is necessary popular method of extraoral osteosynthesis has a
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Section 1. Clinical medicine
number of disadvantages, such as an undue increase of operation injury, a risk of trauma of tooth roots and n. alveolaris inferior, an unstable fixation [1, 32]. In accordance with majority opinion of authors, exactly imperfection of reposition and insufficiency of fixation stability are the basic local factors of origin of the secondary fragments displacements, a low consolidation of fractures, a formation of preudoarthrosis, an adjunction of the secondary infection and development of posttraumatic osteomyelitis [2, 30-33].
It was set in numerous researches ofbiomechanics of lower jaw that after a break in the area of body or corner its anatomical features stipulate the area of functional tension and origin of fragments divergence at the level of alveolar bone, while at the lower border of mandible the compressive strain is dominate and bone fragments in this area do not branch off, but compress [3, 38-41]. In subsequent experimentally and clinical researches was evidently shown, that course of reparative osteogenesis is more optimized and has a close resemblance to the «primary type» if the fixators are located in the area of alveolar bone of lower jaw, than by the extraoral access of osteosynthesis with fixation in the area of the lower border of mandible [4,124-125].
To date the advantages of the use of intraoral access of operation osteosynthesis with superior border plate at the patients with the mandibular fractures are obvious and out of question. Comparative analysis of results of mandibular osteosynthesis by miniplates shows that reduction of traumatic injury by intraoral access is provided the decline of the frequency of different complications development in 2 times, than by extraoral access [5, 25-26].
Traditionally intraoral osteosynthesis is realized by titanic miniplates, rarer by different wire. However, the question of the use of the metallic fixators remains disputable. The development of inflammatory processes as a result of response to a metal, corrosive destruction of fixing construction in consequence of the increase of electrochemical potentials are associated with this method. From positions of biomechanics, bone miniplates can not retain fragments in the correct position in horizontal,
vertical and sagittal planes at once. Ineffectiveness in the cases of comminuted fracture, possibility of reoperating for fixator removal is possible to subsume by the known lacks of miniplates [6, 603-607].
That’s why the interest to the method of polymer osteosynthesis, which is based on the use of I-, T-, X-, Y- similar polyethylene or polylactic acid resorbable miniplates (1,5 mm thick) does not weaken the last years [7, 181-209; 8, 89-96]. Material has good biocompatibility, does not require the repeated operations for the remove of fixators. However, the development of method of polymer osteosynthesis passes while a way of research of optimum biomaterial and, in less degree, takes into account biomechanics of lower jaw at a trauma, especially in the cases of difficult comminuted mandibular fractures, at presence of bone defects.
Thus, our interest was attracted by the method of the directed regeneration of bone tissues, which deserved a wide popularity in dental surgical practice and provide for use of different barrier membranes. The resorbable membranes made of polylactic acid (Polylactic Acid Barrier) widely utilize in a clinic at the difficult bone defects of jaws. Such membranes possess sufficient inflexibility and, in also time, enables to keep under itself volume space, which correspond to topography and size of remodeling tissues and create a reliable barrier to migration of epithelium in the area of regeneration. They establish a reputation for using in combination with osteotropic materials at preimplantation preparation of cavity of mouth, at treatment of periimplantitis, however, it should be noted that in the clinic of maxillofacial traumatology such membranes did not find while application [9, 761-768].
A study of features of application of resorbable membranes from PLLA for fixing of bone fragments in the treatment of the uncomplicated and complicated or comminuted mandibular fractures with the different defects of bone tissues, and also for fixing of bone fragments at patients with posttraumatic osteomyelitis, low consolidation or pseudoarthrosis may be perspective.
Purpose of research: determination of clinical and roentgenological efficiency of membranes from PLLA using for fixing of bone fragments in the
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Prospects for use of resorbable membrane made of polylactic acid in the treatment of mandibular fractures
treatment of the uncomplicated and complicated mandibular fractures.
Materials and methods: In this research 16 patients with the one-sided mandibular fractures in the area of dentition took part, average age was 28,9 ± 7,8 years. All of patients appealed for a medical aid in the day of trauma. A voluntary consent to the participation in a research was obligatory. All of patients initially did not have serious concomitant somatic pathology influencing on the results of treatment.
The advanced clinical, laboratory and roentgenologic examination were carried out before treatment, on the next day after surgical treatment, in a month and 6 months after treatment. Computer tomography of mandible for identification of relation and degree of displacement of bone fragments and sizes of bone defects carried out at the all patients before operative treatment and in 1 month after it.
Mandibular fracture in area of incisors is diagnosed for 4 patients (25% cases), from them 3 patients had a lateral incisor in the line of break, plural small bone fragments were determined in area of frontal part of alveolar socket, for one patient was marked posttraumatic complete dislocation of central incisor and expressed defect of frontal wall of alveolar socket (to 3/4 its length). At 12 (75%) patients a mandibular fracture in area of lower third molar was determined with the expressed separation of bone fragments (to 6-7mm), which reposition
was hampered by a tooth in the line of fracture. Thus, all of patients selected to research, initially had a difficult clinical situation and the local risk factors of development of inflammatory and noninflammatory complications of mandibular fractures.
For all ofpatients the operation ofintraoral polymer osteosynthesis was conducted by the our method (Pat. Ukraine N 96510). An operation was executed after antisepsis by solution 0,02% chlorhexidine, surgical protocol was included the local anesthesia, intraoral access with the use of L-formed (in a retromolar area) or trapezoidal (in a frontal area) incision. After removing of mucoperiosteal flat and skeletization of buccal cortical bone and lingual surface oflower jaw in area of fracture, if it was necessary we extracted a tooth from the line offracture, conducted curettage ofbone wound, removaled nonviable tissues, loose-lying bone fragments of alveolus collected and crushed by a mill to the chips (1,5 mm), the mobile, but intravital fragments of interradicular septa and frontal wall of alveolar socket remained in their places, carried out a hand reposition, filled the alveolar socket of remote tooth and line of fracture by osteoplastic material to renewal of anatomic form, conducted fixation of bone fragments — for this purpose covered the line of break by PLLA membrane, which was adapted to the surface of defect, recovering him from a vestibular side to the lingual, spread the edges of membrane for both sides from the line of fracture on ~15 mm.
Fig. 1. Position of PLLA membrane relative to line of fracture and alveolar socket after teeth extraction in different clinical cases
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Section 1. Clinical medicine
After heating a membrane was laid on an alveolar bone of mandible, try for its dense contact with osteoplastic material. After cooling a membrane was fixed by 4-5 pins from RLLA (on the vestibular and lingual side of jaw), disposing them for both sides from the line of fracture opposite each other. Before wound closure we polished harden edges of membrane by a bone cutter. A mucoperiosteal flat was mobilized and laid over a membrane, fixed by U-shaped suture. For realization of such surgical protocol of mandibular fractures treatment we utilized Hypro-Oss/Alpha Bio’s «GRAFT» (Israel) as osteoplastic material and resorbable plates-membranes made of PDLLA «KLS Martin Group» (Germany) width 2,0 -3,0 mm.
Results and their discussion: After the reposition of bone fragments of lower jaw and their fixation conducted according to the offered protocol with the use of PLLA membrane at all 16 patients a bite was restored completely, fragments mobility absented during clinical monitoring. The high-quality and stable fixation was provided due to accordance a construction to the biomechanics oflower jaw during a trauma: laying and fixing of dense membrane over the alveolar bone in the area of functional tension blocks horizontal divergence of fragments, and 4-5 pins from PLLA (on the vestibular and lingual side of mandible), located for both sides from the line of fracture opposite each other hinder deformation
of twisting and displacement of fragments in a lingual (cheek) side. A postoperative period passed without complications, for all of patients removal of sutures carry out on 7th day after an operation, recommend ambulatory treatment — after 8 days. The mouth opening was restored in full volume to 10th day after an operation.
At the clinical examinations in a month and in 6 months the patients did not have complaints, the union of bone fragments passed by contact osteogenesis without forming of expressed definitive callus. It was determined a full reposition and satisfactory fixation of bone fragments on control roentgenograms and CT. It was not set repeated displacement of fragments. In 6 months after an operation volume of bone tissues in the area of fracture, defects of alveolar bone and wall of socket after teeth extraction restored fully. Any cases did not required additional surgical procedure for the removing of fixators.
Conclusions: Offered method of intraoral polymer osteosynthesis with the use of PLLA membranes for fixing of bone fragments in the treatment of the uncomplicated and complicated mandibular fractures reduces traumatic injury of surgical procedure, provides the reliable fixation during all period of treatment, promotes anatomic and physiologic rehabilitation in the optimum terms.
References:
1. Tymofyeyev O. O., Vesova O. P. Mandibular nerve injures study during lower jaw fractures and dental implantation: International journal of Oral Maxillofacial Surgery, Volume 32 (Supplement 1), 2003.
2. Kopchak A. V. The mistakes and complications while surgical treatment of traumatic fractures of mandibular: Clinical surgery, Kiev, N1, 2013.
3. Artushkevich А. S. Treatment of mandibular fractures according to anatomy and biomechanics: Sovre-mennaya stomatologiya, Minsk, N3, 2001.
4. Resident Manual of Trauma to the Face, Head, and Neck: by edition G. R. Holt, e-Book Format: First Edition 2012. http://www.entnet.org.
5. Clinic and treatment of mandibular fractures at the elderly persons: A. S. Gouk and all., St. Petersburg, Nordmedizdat, 2011.
6. Murthy A. S. Symptomatic plate removal in maxillofacial trauma: a review of 76 cases: Annals of Plastic Surg, Volume 5, N 6, 2005.
7. Habal M. B., Holmes R. E., Cohen S. R. The use of Biomaterials in Craniofacial Trauma: Facial trauma (edited by S. R. Thaller, W. S. McDonald), Miami, Florida, USA, 2004.
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The place and the role of low invasive surgical technologies in the diagnosis and treatment of abdominal trauma with...
8. Laughlin R. M., Block M. S. Resorbable Plates for the Fixation of Mandibular Fractures: A prospective Study: J Oral Maxillofac Surg, Volume 65, 2007.
9. Ashish A. Comparative evaluation of decalcified freeze-dried bone allograft use alone and in combination with polylactic acid, polyglycolic acid membrane in the treatment of noncontained human periodontal infrabody defects: J. Quintessence International, Volume 43, N 9, 2012.
Petruk Dmytro Volodymyrovich, The surgeon of Kamyanets-Podilsky city hospital № 1.
E mail: xipypr.petruk@gmail.com Pidmurnjak Oleksandr Oleksievich, The chif-surgeon of surgical division of Khmelnitsky region hospital, Doctor of medicine.
E-mail: ant-70@mail.ru Arsenyuk Valeriy Viktorovich, The chif-surgeon of Isurgical division of Kamyanets-Podilsky city hospital № 1.
E-mail: grinsv@rambler.ru Shevchuk Vitaliy Ivanovich, The chif-doctor of Kamyanets-Podilsky regional hospital.
E-mail: uahirurg@gmail.com
The place and the role of low invasive surgical technologies in the diagnosis and treatment of abdominal trauma with pancreatic injuries and pancreatitis
Abstract: The article presents the results of applying low invasive surgical techniques in injuries of the pancreas in conditions of concomitant abdominal traumas. Minimally invasive techniques have advantages in improving the accuracy of diagnosis and improve the outcomes of surgical intervention, partially replacing open surgery and expand the technical capabilities of the surgeon.
Keywords: abdominal trauma, trauma of pancreas, diagnostics, treatment, low invasive methodic.
Петрук Дмитрий Владимирович, Каменец-Подольская городская больница № 1, врач-хирург.
E mail: xipypr.petruk@gmail.com Пидмурняк Александр Алексеевич, Хмельницкая областная клиничкская больница, заведующий хирургическим отделением, доктор медицинских наук. E-mail: ant-70@mail.ru Арсенюк Валерий Викторович, Каменец-Подольская городская больница № 1, заведующий хирургическим отделением № 1.
E-mail: grinsv@rambler.ru
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