Nghiên cứu giải phẫu và ứng dụng lâm sàng thần kinh cơ cắn trong điều trị liệt mặt giai đoạn bán cấp tt tiếng anhg

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES BUI MAI ANH ANATOMICAL RESEARCH AND CLINICAL APPLICATIONS OF MASSETER NERVE IN INTERMEDIATE DURATION FACIAL PARALYSIS TREATMENT Speciality: Odonto-Stomatology Code: 62720601 ABSTRACT OF MEDICAL PHD THESIS Hanoi – 2019 Thesis is completed at: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Supervisor: Prof.PhD Nguyen Tai Son Reviewer: The thesis will be defended infront of the Institute-level Council of Thesis Assessment met at:108 Institute of Clinical Medical and Pharmaceutical Sciences at h .in 2019 The thesis can be found at: National Library of Vietnam Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences INTRODUCTION The injury of the nerve VII due to various causes makes paralysis of facial muscles The functions of facial muscles play an important role in communication The injury of the nerve VII also causes some functional effects such as eye protection function There are many studies offering different methods of surgey to reduce facial deformity, but each method of surgery is effective only on each patient and donor nerve that was intervened by surgery Facial nerve injury at an early stage of less than years has the ability to be restored by direct surgical intervention However, the use of adjacent nerves only resolves the problem of active facial vibrations and is not identical to the healthy half-face Facial nerve graft has been studied by many authors for a long time However, this method is still limited Masseteric nerve surgery is used to replace the old method with positive results In Vietnam, surgery for facial paralysis treatment has been carried out for a long time However, there has not been any study on surgery and applications of masseteric nerve in a systematic way, so we conduct research on the topic ”Anatomical research and clinical applications of masseter nerve in intermediate duration facial paralysis treatment” for the following purposes: Course of masseteric nerve anatomy Evaluate results of the applications of masseteric nerve in surgical treatment of intermediate durationfacial paralysis Chapter OVERVIEW 1.1 Masseteric nerve The nerve that regulates masseter musclemovement is called masseteric nerve (MN), a branch from the anterior trunk of mandibular nerve - Branching: According to some studies, MN has branching in some cases - Location: According to Kun Hwang, MN is located at 33 ± 5.6 mm from the lower limit of masseter muscleon the longitudinal line 1/3 before the masseter muscle and 47 ± 5.5 mm from the lower limit on the vertical line 1/3 after - Microscopic anatomy: Through microscopic anatomical results, it can be seen that the number of MN axons is much larger than other nerves, which is one of the good conditions for recovering nerve transmission when it is used as a source 1.2 Surgical methods to restore facial muscles by the time of paralysis 1.2.1 Acute facial paralysis (paralysis time years) - Methods: + Local muscle transfer surgery: the muscle often used is a temporal muscle with the condition that the trigeminal nerve is not injured + Micro-surgical transfer surgery: in cases where the transfer of local muscles is difficult or has not the desired results, the free muscle transfer is a good choice Free muscles are commonly used: slim muscles, large back muscles, small chest muscles, and muscles in form of big toe 1.3 Situation of applications of masseteric nerve in facial paralysis treatment 1.3.1 Masseteric nerve transfer in intermediate durationfacial paralysis treatment ( years) Like the direct transfer of MN, the use of MN for muscle transplantation has many advantages such as ease of surgery, short recovery time, the used nerve does not affect the function However, the authors also said that the use has disadvantages such as when lifting the edge, it is necessary to bite with the bitting and the time to create a natural smile must be 2-4 years after surgery To overcome this problem, some authors have used dual nervous joint with two places: MN and facial nerves with the movement nerves of the grafted muscle to create spontaneous and natural laughs In 2012, Biglioli reported a series of free muscle grafts, with two nervous sources (MN, facial nerves) and very positive results In the future, functional magnetic resonance imaging may be used to study this process in facial paralysis and to explore the cortex areas that are activated while smiling with the patients who use MN as source of free muscle transplantation To achieve in spontaneous way, symmetrical smiles, an important part is due to post-operative recovery of smile function when standing in front of the mirror with exercises and biofeedback 1.3.3 In Viet Nam In Vietnam, peripheral neuropathy joint techniques are also performed by many surgeons in orthopedic, neurosurgical and jaw surgery From the 1990s, N.B Hung (1998), N.H.Phan (1999) used micro vascular-neuromicrosurgical techniques to more accurately suture and join, Dr Son (2000) reported on the technique of suturing and covering the bundle of fibers in the nervous joint and transplant The use of facial nerves in the nerve VII recovery has also been reported by author N.T.Son since 2003, with positive results and one of the options in the facial paralysis treatment Studies on anatomy and MN applications have also been reported, but there have been no further studies on anatomy and application on Vietnamese people Chapter RESEARCH SUBJECTS AND METHODS 2.1 Research subjects - Research on fresh cadaver: 22 specimens /11 fresh cadaver (including men and women) from 35-73 years old, fresh cadaver were studied in Ho Chi Minh City University of Medicine and Pharmacy, 02 fresh cadaver at Viet Duc Hospital, unknown age (unidentified cadaver) - Clinical research: Patients with facial paralysisdue to various causes in the period from weeks to 24 months had surgery to transfer one-sidedness MN at the Department of Maxillofacial Surgery-Plastic Surgery-Aesthetics, Viet Duc Hospital from 11 / 2009-12 / 2017 2.1.1 Selection criteria and exclusion of patients - Criteria for selection on cadaver: The specimens on the fresh cadaver are intact in the face area, have not been surgically or previously injured Exclude specimens that are not properly preserved, face areas are injured - Criteria for patients selection: Patients with facial paralysisaccording to FNGS 2.0 classification from grade to grade for not more than 24 months paralysis; The patients were diagnosed with intermediate durationfacial paralysis; For facial paralysis patients with unidentified paralysis causes (Bell paralysis), the time for surgery indication is more than months if there is no sign of clinical recovery; There are no systemic diseases that endanger the surgery; had surgical treatment in plastic surgery and maxillofacial surgery; Follow up patients after periodic treatment of month, months until the end of the studies 2.2 RESEARCH METHODS 2.2.1 Research design: - Research on fresh cadaver: Observation and description research - Clinical research: Retrospective, prospective, clinical intervention, noncontrolled 2.2.2 Research facilities and equipment - Research on fresh cadaver: + Use surgical instruments, measurer, loupe + Carry out the surgery on each side of fresh corpse, with supine position of the head tilted to the opposite side + Skin incision along Blair incision line from the temple through the tragus to the jaw corner about 1/3 of the length of mandibularbone + Operate of the facial muscle layer, operate to the front bank, the bank on the salivary glands + From the anterior border of the parotid glands, operate to find branches of the nerve VII: the mouth branch, the cheek branch Then retrograde surgery into the parotid salivary glands + Remove the shallow lobe of glands that preserve nerve VII branches + Reveal the whole nerve VII + Continue to remove the deep lobe to expose the entire masseter muscle below + Measure the index of masseter muscle as below + Continue operating the layers of masseter muscle, peeling according to the layers + Find donor nerve and masseter muscle arteries in the deep layer of masseter muscle + Measure indicators - Clinical research: + Clinical examination of the patients: assessing injury status of the nerve VII according to House and Brackmann score (FNGS 2.0); measure commissure excursion amplitude; assessment of facial nerve injury; masseteric muscle function; classify causes of injury; body situation + Subclinical assessment: MRI, CT to search for causes of the nerve VII injury; EMG to determine vulnerability; tests to exclude other diseases + Perform the surgery 2.2.3 Improved content in surgery to find MN Through clinical and anatomical researches on the fresh cadaver, we map out the "MN zone” as follows: + Upper limit: zygomatic branch + Lower limit: buccal branch + Posterior limit: the parallel line and measure the distance from the tragus to the branching position of MN + Anterior limit: the line parallel to the posterior limit and about 1cm from the posterior limit MN zone is limited when connected 04 lines above and in the deep layer of masseter muscle 2.2.4 Follow uppost operation - The patient was monitored at the hospital during 5-07 days - Follow up immediately after surgery about hematoma, bleeding, infection - Periodic observation: 03 months, 06 months, 12 months to assess the time of axon regeneration by manifesting the movement of facial muscles clinically - Evaluation of the time onset of vibration based on the patient perception when biting, it will result in muscle vibrations of the mouth in paralysis side 11 muscle(optional conditions) Type 5: Poor - FNGS 2.0: Grade V, VI - Movement needs bit with bitting - Difference in amplitude of the mouth movement calculeted from the upper lip middle is small or quite zero - Electromechanics: There is no electric potential difference when biting 2.4 Ethics in research - Objectives and methods should be considered carefully so that the benefit of patients is priority - Patients voluntarily participate in research - Information security and use for research purposes 12 Chapter RESEARCH RESULTS 3.1 Research results of MN anatomy Observe 22 cadaver specimens (12 men, 10 women), average age of 69.7; number of bite layers: 3; masseter muscle length: 64.4 ± 3.9; masseter muscle width: 37.4 ± 3.6 The distance from the tragus to the branching point under MN is 33.2 ± 2.6; The distance from the cheek bow to the branching point under MN is 7.8 ± 0.8; The distance from the zygomatic arch to the branching point under MN is 5.8 ± 0.8; The distance from the jaw corner to MN is 54.2 ± 12.6; The distance from the mouth branch of the nerve VII to the branching point under MN is 11.2 ± 3.0 There are no statistically significant differences in men and women There is difference, but not statistically significant between the MN location on the corpse and on the surgery, the distance from the tragus to MN on the corpse is larger than on the surgery but not significant MN was found in the deep layer of the masseter muscle and between the cheekbone branch and the mouth branch of the nerve VII, before the tragus 29.9 ± 2.5 mm 3.2 Surgical results 3.2.1 Short term results Complications after surgery: Infection, fluid accumulation, saliva leakage are not seen in any case The effect of the proximal results is calculated on the time of time onset of vibrationand the commissure excursion movement when biting after surgery Table 3.13.Onset-vibration muscle time with the bitting (n = 32) 13 Time of the first muscle vibration (month) Mean ± SD Min Max Coaptation to the buccal branch (n=23) 3.5 ± 1.1 2–6 Coaptation to the buccal and zygoma branch (n=4) 4.3 ± 1.5 3–6 Coaptation to the main trunk (n=5) 4.6 ± 0.5 4–5 – P 0.045 All the cases (n=32) 4.3 ± 3.7 2–6 Remark: After surgery, the time of the time onset of vibrationwith the bitting is 3.5 ± 1, 07 months; of the group coapted 02 branches is 4.3 ± 1.5 months; with the main body joint group is 4.6 ± 0.5 months and the average is 4.3 ± 3.7 months This difference is statistically significant with p