PDF - Dental and Medical Problems

Original papers
Dent. Med. Probl. 2013, 50, 1, 15–19
ISSN 1644-387X
© Copyright by Wroclaw Medical University
and Polish Dental Society
Yan Vares1, A, D, E, Anton Filipskyi1, B, D, E, Askold Kucher2, B, Tetyana Filipska3, B, E, F Application of Intraoperative Ultrasonography
in Open Reduction of Mandibular Angle Fractures
Zastosowanie ultrasonografii w śródzabiegowej kontroli
repozycji fragmentów kostnych z złamaniach kąta żuchwy
Department of Oral and Maxillofacial Surgery, Lviv Danylo Halytsky National Medial University, Lviv, Ukraine
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
1
2
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 intraoperative 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 traumatic 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 complications 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 traumatic 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.
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Y. Vares et al.
Cel pracy. Ocena wartości diagnostycznej ultrasonografii jako metody śródzabiegowej kontroli repozycji fragmentów 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 złamaniem kąta żuchwy, hospitalizowanych na Oddziale Chirurgii Szczękowo-Twarzowej Lwowskiego Regionalnego
Klinicznego Szpitala we Lwowie w latach 2008–2011. W czasie hospitalizacji pacjenci byli badani pantomograficznie i ultrasonograficznie z użyciem transduktora elektronowego (LOGIQ E® General Electric) z głowicą o częstotliwości 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 repozycji fragmentów do pozycji anatomicznej i po stabilizacji ich minipłytkami. W okresie pozabiegowym pacjenci byli
badani pantomograficznie na 2.–3. dzień po zabiegu. Nie stwierdzono żadnych powikłań podczas kontroli pozabiegowej. 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.
A negative consequence of the rapid development of science and technology is a steady increase
in domestic and industrial injuries. According to
statistics [1–3] traumas of maxillofacial area, particularly 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. Today increasingly popular among doctors are ways
of intraoral mandibular ostheosynthesis [3–10].
However, the main disadvantage of such technique is insufficient visualization of the lower edge
of the jaw [11]. No intraoperative radiation monitoring 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-
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
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 directed its attention to the method of ultrasonography, which has long been used as intraoperative 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 medical diagnostics of patients with injuries of the ankle 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] successfully applied it for preoperative diagnostics of patients with traumatic midface fractures, and Gülicher 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 value of ultrasonography in maxillofacial traumatology, especially in traumas with angular fracture.
The data of our previous studies [19–21] concerning the application of ultrasound to diagnose osseous pathology in maxillofacial area completely
correlate with the information of our foreign colleagues. These data have become the scientific basis to continue researching the possibilities of ultrasonic method as intraoperative monitoring of
fragment repositioning, particularly of the mandibular angle [22].
Application of Intraoperative Ultrasonography in Open Reduction of Mandibular Angle Fractures
17
The objective of this study was to determine the
diagnostic value of ultrasonography as a method of
intraoperative monitoring of the quality of bone element repositioning in the region of the mandibular angle during intraoral osteosynthesis.
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 Lviv Regional Clinical Hospital 2008 to 2011 with traumatic
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 osteosynthesis with mini
plate [6]. During the surgery ultrasound monitoring was conducted twice: after fragment repositioning into anatomic position and following the
fixation of them. During the postoperative period all patients underwent control orthopantomography on the 2nd–3rd day after the surgery. There
were no complications in the postoperative period. X-ray revealed close contact between the fragments 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 medial 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) confirmed the displacement (3.34 mm), revealed dislocation 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 continuity of the bottom edge of the jaw.
In the postoperative period the control orthopantomogram was conducted (Fig. 5). It shows
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
fracture fixation with mini plate in the anatomical
position, which is totally confirmed by intraoperative ultrasound.
Conclusions
Summarizing the conducted research on the
use of ultrasonography in the diagnostics of in-
18
Y. Vares et al.
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
juries in the maxillofacial area, authors’ previous experience and the results obtained in this
work, high diagnostic value of the method is obvious when it is used as intraoperative monitoring of fragment repositioning due to availability of
Fig. 5. Control orthopantomogram of the patient M.
after surgery
Ryc. 5. Zdjęcie pantomograficzne pacjenta M.
po zabiegu chirurgicznym
many projections, symmetry and standard access.
Consequently the method of intraoperative ultrasonography is appropriate to implement in routine
medical diagnostics of patients with traumatic injuries of the mandibular angle.
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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: [email protected]
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.
Zaakceptowano do druku: 24.01.2013 r.