nghiên cứu áp dụng nẹp vít tự tiêu trong điều trị gãy xương hàm dưới bản tóm tắt tiếng anh

INTRODUCTION Maxillofacial trauma is a common emergency in everyday life, increases significantly in recent years and tends to be more serious and complicated about amount of fracture line, more displaced, combines with soft tissue, blood vessel - nerve, brain injury or coordinate with trauma of other parts of the body, is mainly due to traffic accidents, specially motorcycle accident. In these traumas, mandibular fracture has the highest percentage, is being a heed matter, particularly in developing countries (Vietnam, Turkey, Africa ). According to Balwant Rai et al (2007), this kind of fracture occupied 61% in kinds of maxillofacial fracture. In Vietnam, a research of Tran Van Truong and Truong Manh Dung in National Hospital of Odonto- Stomatology (1988 - 1998), with 2149 cases of maxillofacial trauma, mandibular fractures was the most common (63.66%) and was mainly due to traffic accidents (82.5%). The lower jaw is a main bone, to form the structures of middle face, and is the only moveable bone of the skull blocks. On this, there are teeth and muscles attached to make chewing function, expressing emotion, particularly this bone has a curved body with several weaknesses, such as the angle of the jaw, middle lines, neck of condyle, so it is easy to be broken. The purpose of treatment is not only maintaining chewing function but also aesthetics. The choice of methods and materials for surgery is very important, determines the result of the surgery. In recent years, there are so many plate and screw system are used in combination lower jaw, achieves good results, the rigid fixed after surgery to help healing process faster, avoid secondary displacement, fixed time is shortened. In the world, absorbable material (plates and screws) first appeared in the United States since the early 90 th decade of the twentieth century, is a good technical solution cause it has inherited the advantages of conventional material, with the rigid, stable feature between a fracture; has overcome the 1 disadvantages of removing the screw and bands for patients to avoid the secondary surgery, both economical cost, time -consuming as well as bad scars, affects the aesthetics and psychology of the patient. In addition, absorbable screw can play a same role as tissues when being treated by radiation therapy after surgery, another benefit is the ability of transparency, easy for diagnosis postoperative X-ray imagines. In pediatric patients, treatment and orthopedic surgery becomes easier because they do not prevent the development of bone. Today, this system has highly compatible feature, is being widely used and prospectively an ideal treatment for trauma, especially be good for children or maxilla. However, the existed problem for some developing countries is still high cost. Initially, absorbable material only uses limitedly in brain surgery (such as craniosynostosis, brain hernia), then in combination between the middle-level facial bone and orthopedic surgery. With the mandible, they also doubt the effectiveness of this material, recently there is few reports shows the success of using absorbable screws in the lower jaw surgery. In Vietnam, absorbable material is put into use in recent years, however, it is on trial, and the amount of research is not enough. So that, in order to study and apply and technology of combination the mandible by absorbable material, we did a research: "Applying absorbable material on mandibular fracture treatment" with the two following goals: 1. Comment on the clinical morphologic of mandibular fractures. 2. Review the result of the technology of fixing the mandible by absorbable material, compare with Titanium material. * Layout of the thesis The thesis consists of 99 pages, 2 pages for introduction and 2 pages for conclusion. This includes four chapters: Chapter 1 about literature review has 38 pages, chapters 2 about subjects and methods has 14 pages, chapter 2 3 about research result has 20 pages, chapter 4 about discussions has 24 pages. There are 36 tables, 6 charts and 20 figure, 102 book references: 32 Vietnamese ones, 66 English ones, 4 French ones. The appendix includes illustrations of patients, medical records, patient list. * Meaning and new contributions of the thesis This method brings the results which is not different from the usage of Titanium material when having accurate indication. During doing a research, we found that the application of this method has some advantages: - The biggest advantage is that the patient does not have to proceed to the second surgery to remove the plates and screws, this is significant for female patients, thereby helping patients quickly regain confidence, do not have to worry about having to remove the material. - The material is absolutely preserved in a sterilization condition, in the process of studying, we have not seen any complications of patients wound like infection or osteitis. - This is biomaterials, does not affect the diagnostic imaging (X-ray, MRI). - About aesthetics: No difference from the usage of Titanium because the absorbable material does not occupy more volume than the maxi Titanium plate. CHAPTER 1. LITERATURE REVIEW 1.1. ANATOMICAL FEATURES OF MANDIBLE RELATE TO TRAUMA Mandibular region is formed by two bones, stick together at the centre and the soft tissues around. Border: The zygoma and maxillary above, inframandibular edge beneath, the mental area is ahead, the back of ramus behind. 3 1.1.1. Shape Mandible is a flat bone, horseshoe-shaped, protruding out frontal surface , including 2 parts: body and ramus. It is porous inside, thick and rigid outside, each side has a tube that the mandibular nerve and blood vessel go through. There are many tooth implanted in the cancellous bone . 1.1.2. The weak points of mandible - Incisal area, mental foramen, gonion, neck of condyle. 1.1.3. The muscles around and the direction of displacement of the fractured bone These muscles (except the buccinator) are responsible for chewing and movement, divided into two groups with opposite forces. * Lifting the mandible: - Maseter, temporalis muscle, the internal pterygoid. * Lowering the mandible: - The external pterygoid, mylohyoid, geniohyoid, genioglossus, the anterior digastrics. When the bone break, the muscle pulls the fragment towards its own direction, leads to the displacement. It can be in 3-dimensional space plane: vertical plane (up and down movement), horizontal plane (right and left movement), the front vertical plane (twisting). 1.2. CLINICAL SYMPTOMS AND X RAY 1.2.1. Clinic symptoms a) Swelling and hematoma b) Discontinuous bone and sharp pain - These are important signs to diagnose fracture. 4 c) Deformity d) Discontinuous and displaced dental arch: d) Malocclusion e) Mobility of tooth, alveolar bone, gum injury f) Soft tissue injury: g) Mandibular movement disorder, including limitation of mouth opening and deviation to the contralateral. h) Paraesthesia i) Subcutaneous emphysema: rare. 1.2.2. X-ray fracture 1.2.2.1. Survey the entire mandible a) Panoramic films - The vertical displacement on the bottom can be assessed very good on panoramic films, in the fracture of neck’s condyle shows the displacement between ahead and behind, the relationship between condyle and mandibular fossa. b) Facial X-ray: - Assess of the horizontal displacement of the fracture, compare with the proportions of the whole mandible. 1.2.2.2. Films examined the region of the mandible (Oblique jaw film) 1.2.2.3. CT Scanner (CT: Computerized tomography) To get clarity, accuracy of lesion and location (both bones and soft tissues) of most mandibular fracture. 3 dimensional images show clearer about displacement pattern and degree of fracture displacement. 1.3. COORDINATE INJURIES 5 Brain injury has the highest percentage (9.5%), the second is coordinated with maxillary fracture (5.2%), then zygomatic fractures (2.2%). Injuries coordinated with other parts such as limbs, chest, abdomen, spine appear with lower rates. 1.4. TREATMENT 1.4.1. The goal of treatment - Recovery of anatomy - Recovery of function - Recovery aesthetics 1.4.2. Requirements - Bend fractures corrected - Fix fracture bones - Prevent complications. 1.4.3.Fixing by plate and screw - The basic technique + Adjust fractures to the correct position, correct occlusion, temporary fixation dental archs. + Put a sample plate on surface of bone and bend it. + Bend the plate following the curve of the sample one. + Put the plate on the surface of bone, keep it tightly by pliers, and drill the first hole on the compressed position (pear shape), off-center position. + Screw (not tightened). + Drill the second hole in remained compressed position and screw. 6 + Gradually twist tightly the screws both sides to the most tighten to press the fracture together. + Drill and screw in the middle position. + Remove the equipment, check anatomical landmark and occlusion. After surgery the patient does not have to fix jaws or just fix in a short time (1-2 weeks). - Use absorbable material in the treatment: Absorbable material is easy to use as Titanium and does not need more surgery to remove due to the process of biodegradation the material transfer to C0 2 and H 2 O. This process starts after 6 months and lasts on average 36-60 months by two stages (hydrolysis and absorption) with the combination of the metabolic cycle of Citric acid (Krebs Cycle ). - Advantages of absorbable material It is created from the natural compounds. Not only meets the treatment, inherits the advantages of the metal plate and screw, but also overcome the disadvantages of metallic material. - Indication: + Facial and skull fractures. + Nasal fracture, anterior walls of sinuses, lateral orbital wall, the floor of orbital. + Replicate the facial bones and skull. + Replicate the jaw bone (bone graft). - Contraindications + Acute infection. 7 + Poor blood supplying in the position which plates are put on, bone defects, high risk of infection. + Not use for high pressure position + Temporomandibular joint surgery. In my research, we use the products of Bio Tech One. CHAPTER 2 SUBJECTS AND METHODS 2.1. SUBJECTS The patients have mandibular fracture, are indicated for surgery at the Department of Orthopedic Surgery in National Hospital of Odonto Stomatology and Department of Odonto Stomatology, E hospital from January 2008 to August 2012. 2.1.1. Requirement - Being diagnosed mandibular fractures with 1 or 2 lines, very little displaced. - Combine mandible by absorbable and Titanium material. - Be volunteer to participate in research. - Intervention group using absorbable material. - Control group using Titanium material. 2.1.2. Exclusion - Mandibular fracture or bone defects due to pathology. - Plenty of fractures, complex fractures. 8 - Psychiatric patients or chronic diseases affect the bone healing process. - Uncooperative patients. 2.2. LOCATION AND TIME Department of maxillary surgery in National hospital of Odonto- Stomatology and Department of Odonto- Stomatology in E hospital from January 2008 to August 2012. 2.3. METHODOLOGY 2.3.1. Kind of research - Clinical controlled intervention trial 2.3.2. Sample Consists of 60 eligible patients, were divided into two study groups: absorbable material group has 30 patients (intervention group) and Titanium group has 30patients (control group). 2.3.3. Information collection: 2.3.3.1. Patient information 2.3.3.2. Clinical 2.3.3.3. Subclinical: X-ray, laboratory 2.3.3.4. Evaluation of treatment results: * Review the results before discharge (according to Table 2.2): Table2.2.Standards for evaluating the results of treatment before discharge. Factor Result Hard tissue Soft tissue Good - Correct border - Correct occlusion in the central occlusion - No swelling, no deformation - Incision is dried - No having the feeling of unpleasant 9 Medium - A little deviated border (≤1mm) - Open bite ≤1mm at the fracture position - A little swelling and deformed - Incision is dried - A little stimulant at which the plate was put on, patient feel acceptable Bad - Much deviated border (>1mm) - Open bite >1mm - Much deformed, need surgery - Very unpleasant, patients complain * Review the results after 6 weeks and 3 to 6 months: Table 2.3. Evaluation based on the standard of anatomy, function and aesthetics. Degree Anatomy Function Aesthetics Good - Good healing - Good in contact between two fragments (displacement < 1mm) - No pain, eat well - TMJ moves well - Amplitude of opening mouth ≥ 40mm - Correct occlusion - Proportional face - No deformation of bone and soft tissue Medium - Good healing - Displaced between 2 fragments about 1-2mm - Less pain, eat normally - TMJ normally - 20mm < Amplitude of opening mouth < 40mm - Correct occlusion - Proportional face - A little deformation of bone and soft tissue Bad - Bone healing time lasts longer - Incorrect healing > 2mm or pseudo- joint - Need reoperation - Pain, hard chewing - Limited TMJ movement - Amplitude of opening mouth ≤ 20mm - Incorrect occlusion - Need reoperation - Unproportional face, deformation of bone and soft tissue. - Need reoperation 2.4. ANALYSE THE DATA: Collecting, summarizing data by biostatistics algorithmic, SPSS 16.0 software. CHAPTER 3: RESULTS 3.1. CHARACTERISTICS OF SUBJECTS 3.1.1. Gender 10 . fracture occupied 61% in kinds of maxillofacial fracture. In Vietnam, a research of Tran Van Truong and Truong Manh Dung in National Hospital of Odonto- Stomatology (1988 - 1998), with 2149 cases of maxillofacial