Original papers
Yan Vares
1, a, D, e, anton Filipskyi
1, B, D, e,
askold Kucher
2, B, Tetyana Filipska
3, B, e, FApplication of Intraoperative Ultrasonography
in Open Reduction of Mandibular Angle Fractures
Zastosowanie ultrasonografii w śródzabiegowej kontroli
repozycji fragmentów kostnych z złamaniach kąta żuchwy
1 Department of Oral and Maxillofacial surgery, lviv Danylo Halytsky national Medial University, lviv, Ukraine 2 Department of radiologic Diagnostics of postgraduate education Faculty, lviv Danylo Halytsky
national Medial University, lviv, Ukraine
3 Department of Maxillofacial surgery, regional Clinical Hospital of the lviv region, lviv, Ukraine
A – concept; B – data collection; C – statistics; D – data interpretation; E – writing/editing the text; F – compiling the bibliography
Abstract
Background. Traumatic fractures of lower jaw are the most common among all of maxillofacial injuries. statistically
the most frequently injured area of the mandible is the angle. it is known that mandibular angle fractures require particular attention to diagnostic and treatment procedures. nowadays the majority of these injuries are treated by open reduction methods using an intraoral approach. in spite of good aesthetic outcomes intraoral approach to mandibular angle cannot provide adequate control of lower border of the mandible during reduction of the fragments. This problem can be solved by using ultrasonography as intraoperative control in open reduction of mandibular fractures.
Objectives. The aim of this study was to determine the diagnostic value of ultrasonography as a method of
intra-operative monitoring of the quality of bone element repositioning in the region of the mandibular angle during intraoral ostheosynthesis.
Material and Methods. The study included 18 patients (17 men and 1 woman) aged 18 to 55 hospitalized in the
Department of Maxillofacial surgery of regional Clinical Hospital of the lviv region from 2008 to 2011 with trau-matic fractures of the mandibular angle. During hospitalization all patients underwent orthopantomography and ultrasound linear electronic transducer using the device (lOgiQ e®, general electric) with operation frequency range of 7.5–12 MHz in b-mode in compliance with all rules of orthopedic ultrasonography.
Results. Treatment of patients was conducted by intraoral monocortical ostheosynthesis with mini plate. During
the surgery ultrasound monitoring was conducted twice: after fragment repositioning into anatomic position and following the fixation of them with mini plate using the above algorithm. During the postoperative period all patients underwent control orthopantomography on the 2nd–3rd day after the surgery. There were no complica-tions in the postoperative period. X-ray revealed close contact between the fragments.
Conclusions. During the study the high diagnostic value of method was confirmed. Consequently the method of
intraoperative ultrasonography is appropriate to implement in routine medical diagnostics of patients with trau-matic injuries of the mandibular angle (Dent. Med. Probl. 2013, 50, 1, 15–19).
Key words: mandibular angle fractures, ostheosynthesis, ultrasonography.
Streszczenie
Wprowadzenie. Złamania żuchwy są najczęstszym urazem kości twarzy. najczęstszym umiejscowieniem tych
łamań jest kąt żuchwy. Większość złamań żuchwy leczy się obecnie operacyjnie metodą osteosyntezy z dojściem wewnątrzustnym. pomimo dobrych wyników estetycznych dostęp ten nie zapewnia właściwej kontroli dolnego brzegu żuchwy przy repozycji fragmentów kostnych. Trudność ta może być zminimalizowana dzięki zastosowaniu ultrasonografii w kontroli repozycji fragmentów kostnych, jako kontroli śródzabiegowej w chirurgicznym leczeniu złamania kąta żuchwy.
Dent. Med. probl. 2013, 50, 1, 15–19
a negative consequence of the rapid develop-ment of science and technology is a steady increase in domestic and industrial injuries. according to statistics [1–3] traumas of maxillofacial area, par-ticularly the mandibular angle, certainly appear among the most frequent injuries. Taking it into consideration, angular fractures require special attention in terms of treatment and diagnosis. To-day increasingly popular among doctors are ways of intraoral mandibular ostheosynthesis [3–10]. However, the main disadvantage of such tech-nique is insufficient visualization of the lower edge of the jaw [11]. no intraoperative radiation moni-toring over the reposition of fragments manifests itself on postoperative radiographs as the presence of gap between the elements (Fig. 1).
Operative X-ray machines and CT scanners are widely used in the world medical practice for intraoperative monitoring of fragment
reposition-ing. However, along with high diagnostic features of these techniques there are such disadvantages as high cost of the equipment, additional radiation exposure and operating personnel.
Therefore the global medical community di-rected its attention to the method of ultrasonog-raphy, which has long been used as intraopera-tive monitoring in general traumatology. Brasseur and Zeitoun-eiss [12] applied the ultrasound for the diagnosis and evaluation of the treatment of acute disorders of the shoulder joint. Boutry et al. [13] successfully applied this method in the medi-cal diagnostics of patients with injuries of the an-kle joint. similar results were obtained by national professionals [14] in the diagnosis of pathological conditions of the musculoskeletal system.
regarding the use of ultrasonic scanning in maxillofacial surgery Friedrich et al. [15] success-fully applied it for preoperative diagnostics of pa-tients with traumatic midface fractures, and güli-cher et al. [16] used this method as intraoperative diagnostics in the osteosynthesis of fractures of the zygomatic bone and the arch. gateno et al. [17] drew their attention to the ability of sonography to diagnose the dislocation of articular process of the mandible after traumas, osteotomies etc. and practiced methods of examining such patients. a team of scientists led by Hirai et al. [18] carried out a series of studies to clarify the diagnostic val-ue of ultrasonography in maxillofacial traumatol-ogy, especially in traumas with angular fracture. The data of our previous studies [19–21] concern-ing the application of ultrasound to diagnose os-seous pathology in maxillofacial area completely correlate with the information of our foreign col-leagues. These data have become the scientific ba-sis to continue researching the possibilities of ul-trasonic method as intraoperative monitoring of fragment repositioning, particularly of the man-dibular angle [22].
Cel pracy. Ocena wartości diagnostycznej ultrasonografii jako metody śródzabiegowej kontroli repozycji
fragmen-tów kostnych podczas wewnątrzustnej osteosyntezy złamania kąta żuchwy.
Materiał i metody. Do badań włączono 18 pacjentów (17 mężczyzn i 1 kobietę) w wieku od 18 do 55 lat, ze
zła-maniem kąta żuchwy, hospitalizowanych na Oddziale Chirurgii szczękowo-Twarzowej lwowskiego regionalnego Klinicznego szpitala we lwowie w latach 2008–2011. W czasie hospitalizacji pacjenci byli badani pantomograficz-nie i ultrasonograficzpantomograficz-nie z użyciem transduktora elektronowego (lOgiQ e® general electric) z głowicą o częstotli-wości 7,5–12 MHz w projekcji b i uwzględnieniem wszystkich zasad ultrasonografii ortopedycznej.
Wyniki. leczenie chirurgiczne było przeprowadzone z wykorzystaniem wewnątrzustnej osteosyntezy złamania kąta
żuchwy minipłytkami. W czasie zabiegu kontrola ultrasonograficzna była przeprowadzona dwukrotnie: po repozy-cji fragmentów do pozyrepozy-cji anatomicznej i po stabilizarepozy-cji ich minipłytkami. W okresie pozabiegowym pacjenci byli badani pantomograficznie na 2.–3. dzień po zabiegu. nie stwierdzono żadnych powikłań podczas kontroli pozabie-gowej. na zdjęciach pantomograficznych potwierdzono ścisły kontakt między zespolonymi obszarami kostnymi.
Wnioski. potwierdzono wysoką wartość diagnostyczną metody ultrasonografii w leczeniu złamań żuchwy. Dlatego
można rekomendować to obrazowanie jako postępowanie standardowe w tym leczeniu (Dent. Med. Probl. 2013,
50, 1, 15–19).
Słowa kluczowe: złamania kąta żuchwy, osteosynteza, ultrasonografia.
Fig. 1. Orthopantomogram of the patient p. aged 23
after the treatment. The diagnosis was the left angular traumatic mandibular fracture. Fracture line is marked with circle
Ryc. 1. Zdjęcie pantomograficzne pacjenta p. w wieku
23 lat po leczeniu. rozpoznanie: urazowe złamanie kąta żuchwy po stronie lewej. szparę złamania oznaczono kołem
The objective of this study was to determine the diagnostic value of ultrasonography as a method of intraoperative monitoring of the quality of bone el-ement repositioning in the region of the mandibu-lar angle during intraoral osteosynthesis.
Material and Methods
The study included 18 patients (17 men and 1 woman) aged 18 to 55 hospitalized in the De-partment of Maxillofacial surgery of lviv region-al Clinicregion-al Hospitregion-al 2008 to 2011 with traumatic fractures of the mandibular angle. During hospi-talization all patients underwent orthopantomog-raphy and ultrasound linear electronic transduc-er using the device lOgiQ e® (gentransduc-eral electric) with operation frequency range of 7.5–12 MHz in b-mode in compliance with all rules of orthopedic ultrasonography.
Results
Treatment of patients was conducted by in-traoral monocortical osteosynthesis with mini plate [6]. During the surgery ultrasound monitor-ing was conducted twice: after fragment reposi-tioning into anatomic position and following the fixation of them. During the postoperative peri-od all patients underwent control orthopantomog-raphy on the 2nd–3rd day after the surgery. There
were no complications in the postoperative peri-od. X-ray revealed close contact between the frag-ments with no displacement.
Clinical example is the case of the patient M. aged 21 with the left angular traumatic fracture of the mandible; traumatic fracture of the medi-al root of the tooth 38. in the preoperative time the patient underwent orthopantomography (Fig. 2) which revealed a solution of continuity of the mandible in the region of the left corner with the small vertical displacement of fragments and root fracture of the tooth 38. Ultrasonography of the area of the left mandibular angle (Fig. 3) con-firmed the displacement (3.34 mm), revealed dis-location of fragments and established the distance between the fragments. Treatment was conducted by intraoral osteosynthesis of the left mandibular angle using mini plate and removing the tooth 38 from the fissure of fracture.
intraoperative ultrasound (Fig. 4) revealed matching of fragments in their anatomic position in close contact between and restoring the conti-nuity of the bottom edge of the jaw.
in the postoperative period the control or-thopantomogram was conducted (Fig. 5). it shows
fracture fixation with mini plate in the anatomical position, which is totally confirmed by intraopera-tive ultrasound.
Conclusions
summarizing the conducted research on the use of ultrasonography in the diagnostics of
in-Fig. 2. Orthopantomogram of the patient M. at the
time of admission. The diagnosis was the left angular traumatic fracture of the lower jaw, traumatic fracture of the medial root of the tooth 38. Fracture line is marked with circle
Ryc. 2. Zdjęcie pantomograficzne pacjenta M. w wieku
21 lat podczas leczenia złamania kąta żuchwy po stronie lewej. rozpoznanie: szpara złamania obejmuje korzeń bliższy zęba 38. szparę złamania oznaczono kołem
Fig. 3. preoperative ultrasonography of the area of the
left mandibular angle of the patient M. The edges of the fragments are marked with points
Ryc. 3. przedzabiegowa ultrasonografia kąta żuchwy po
stronie lewej u pacjenta M. Brzegi odłamów kostnych są oznaczone punktami
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Fig. 4. intraoperative ultrasound of the area of the left
mandibular angle of the patient M. after repositioning the fragments
Ryc. 4. Śródzabiegowa ultrasonografia rejonu kąta
żuchwy po stronie lewej u pacjenta M. po zakończeniu repozycji fragmentów kostnych
Fig. 5. Control orthopantomogram of the patient M.
after surgery
Ryc. 5. Zdjęcie pantomograficzne pacjenta M.
po zabiegu chirurgicznym
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Address for correspondence:
anton Filipskyi
Department of Oral and Maxillofacial surgery lviv national Medical University
69 pekarska str. 79-000 lviv Ukraine e-mail: anton220@yandex.ru received: 3.12.2012 revised: 21.01.2013 accepted: 24.01.2013
praca wpłynęła do redakcji: 3.12.2012 r. po recenzji: 21.01.2013 r.
