Fortschritte der Kiefer- und Gesichts-Chirurgie最新文献

Retrospective analysis of 712 patients with 1166 mandibular fractures and follow up-study of 374 patients with 593 fractures was performed for discrimination of differences in wound- and bone-healing as well as late results between operative and conservative fracture treatment. 46.1% (328) of all patients have been treated conservatively, 53.9% (384) have been treated by operation. The follow up was performed on 255 patients with operative fracture treatment and 119 patients with conservative treatment. In 3.0% of the operatively treated patients bacterial infections occurred, in comparison to 8.7% of conservatively treated patients. From the viewpoint of functional aspects, such as occlusion, articulation and mandibular movement as well as radiological signs in the fractured region patients after operative treatment have shown partly significantly better results during the follow up compared to the group of conservatively treated patients. Neurological testings of inferior alveolar nerve and mental nerve have shown significantly better results in the group of conservatively treated patients. Since the functional results are much better after operative treatment, osteosynthesis with miniplates should be performed if there are no contraindications. The more precise reconstruction and stabilization of the fragments shortens time of hospitalization and leads to sooner functionality of the mandible.

The success or failure of intraoral miniplate osteosynthesis is mainly influenced by right indication. More than 90% of the fractures of the mandible were treated successfully by intraoral noncompressive miniplate osteosynthesis. Hence a postoperative intermaxillar fixation seems not to be necessary. Considering the range of indication this is an effective method of no complications. Nevertheless an immobilisation for one week is accepted by our patients without any problems and is recommended according to normal healing. The collective of our patients in Essen is selected as unilateral multiple fractures, comminuted fractures and infected fractures of the mandible were not treated by miniplate osteosynthesis.

The surgical treatment of different types of mandibular fractures requires complex consideration. It can be realised not by the application of only one treatment concept, e.g. miniplates or rigid osteosynthesis, but a differentiated indication of every stability system depending on the individual requirements in each case. Basing on the results of clinical studies the contemporary concept applied at Münster in treatment of mandibular fractures is presented.

Late results and complications following rigid internal fixation of mandibular fractures-a 10 year survey. From 1984 to 1993 541 fractures of the mandible in 332 patients have been treated by rigid internal fixation with the mandibular compression system (MCS). In 0.8% we saw serious complications like pseudarthrosis or osteomyelitis. In a retrospective study 105 patients with 171 fractures of the mandible could be examined 4.1 years after osteosynthesis. In case of preoperative normesthesia of the inferior alveolar nerve in 74.1% of the fractures nomesthesia was still present, 18.1% of the fractures showed hypesthesia and 4.2% showed complete anesthesia. In case of already preoperatively existent hypesthesia in 81.8% of the fractures normesthesia and in 8.2% hyp- or paresthesia were seen. There were no anesthesias seen in this group. 3.6% of the fractures showed mild occlusal disharmonies.

In a case series 54 patients with 61 subcondylar fractures had been treated by surgical repositioning and miniplate-fixation by an intraoral approach. Functional results with special regard to the function of the temporomandibular joint TMJ were registered not earlier than 1 year postoperatively and compared to a case series of 48 patients with 63 conservatively treated subcondylar fractures. Axiographic or pantographic investigation proved higher incidence of TMJ-disorders as it was the case for the common clinical functional examination. TMJ-function was worse in the conservatively treated cases especially in dislocated fractures. Therefore dislocated fractures especially with luxation of the TMJ should be surgically treated. Surgical repositioning and fixation by an intraoral approach is difficult and allows only limited access and view of the fracture, but avoids complications by scaring or facial nerve damage and seems to be sufficient for adequate repositioning. Minor dislocations showed no influence on TMJ-function. Of course surgical repair of disrupted TMJ-ligaments is not possible by an intraoral approach-disrupted TMJ-ligaments in luxated joints seem to be of major importance for the later TMJ-function.

Disturbances of facial growth and occlusion as well as temporomandibular joint dysfunction are possible sequelae of temporomandibular joint fractures in children. In a follow-up study we examined 30 children with conservatively treated condylar fractures of the mandible (age at time of accident from 9 months to 13 years) regarding dysfunction or growth disturbances within the stomatognathic system. The mean interval between the accident and the follow-up was 4 years and 11 months. We found 6 cases with tilted occlusional planes in the 'en face' analysis, 3 of them with bilateral condylar fractures. There was only one case with a facial asymmetry. The interincisive distance was never below 35 mm. Only 3 patients, all of them with bilateral condylar fractures, had a restricted mobility of the mandible. Remodelling of the condylar head was good in 92% of the cases. Two patients with bilateral fractures showed formation of a bifid condyle without ankylosis. Deviation of the ascending ramus in the horizontal plane was observed radiographically in 21% of the cases with unilateral fractures and in 33% with bilateral fractures respectively and always in a medial direction. Measurement of the length of the Processus articularis in the orthopantomogramm showed a shortening in 70% of the cases on the fracture side. The radiographic evaluation of facial asymmetry after Ricketts and Mulick only revealed an angle difference of more than 5 degrees in some cases.

16 patients with a total of 25 condyle neck fractures, of which 17 were fractures with luxation, 4 fractures with dislocation and 4 diacapitular fractures, were checked clinically and using x-ray and nuclear magnetic resonance diagnosis. Except for the diacapitular fractures, all fractures were treated surgically and fixed functionally stable using mini plates or lag screw osteosyntheses. The examination results show that in the majority of cases a regular discus position and joint function appears along with the repositioning of the condyle neck.

The lag screw technique for treatment of simple median and paramedian fractures of the mandible is reemphasized. Major advantages over bone-plate fixation are the rapid application since adapting and bending of a bone plate is obviated as well as the lower costs of the osteosynthesis material. A review of 12 patients with fractures of the anterior mandible who had lag screws placed for fracture treatment showed that it is a successful method of providing rigid internal fixation associated with a low postsurgical complication rate.