Анализ и профилактика интраоперационных осложнений хирургического лечения пациентов с врожденными аномалиями челюстей
Authors: Сорвин В.А. , Дробышев А.Ю. , Куракин К.А. , Клипа И.А. , Шипика Д.В. , Заборовский В.В. 
Published: December 2024

Цель исследования. Основной задачей ортогнатической хирургии является достижение лицевой гармонии и коррекция скелетных деформаций челюстей и окклюзии. В ортогнатической хирургии обязательное место занимает предхирургическая подготовка, хирургическое планирование и постхирургическое ортодонтическое ведение пациента. На различных этапах лечения пациентов могут возникать различные ошибки и осложнения. Основной целью данного исследования является анализ осложнений хирургического лечения пациентов на интраоперационном этапе сравнение структуры операций по частоте осложнений в отдельные годы периода 20122017 гг., сравнение частоты встречаемости осложнений разной локализации, сравнение частоты встречаемости осложнений разной степени тяжести и создание современной рабочей классификации осложнений. Материал и методы. В период с 2012 по 2017 г. проведено 1329 ортогнатических операций в КЦ ЧЛПХ и стоматологии МГМСУ. Все пациенты, поступающие в клинику КЦ ЧЛПХ и стоматологии МГМСУ были консультированы челюстно-лицевыми хирургами совместно с врачами-ортодонтами и смежными специалистами по показаниям. Комплексное обследование пациентов включало в себя клиническое обследование, осмотр лица и полости рта, антропометрическое исследование лица и гипсовых моделей челюстей, рентгенологическое исследование челюстно-лицевой области (компьютерная томография), фотометрическое исследование лица пациента, магнитно-резонансная томография височно-нижнечелюстного сустава. Среди 1329 операций было выявлено 89 клинических случаев интраоперационных осложнений. На основе данных отделения челюстно-лицевой и пластической хирургии, и данных мировой литературы была составлена и предложена классификация интраоперационных осложнений хирургического лечения пациентов с врожденными аномалиями челюстей. Результаты. По результатам частота встречаемости осложнений по годам статистически значимо различалась: в 2015 г. осложнений было меньше, чем в 2012 г. В 2016 г. осложнений было меньше, чем в 2012 и 2013 гг. Таким образом, число осложнений в период с 2012 по 2017 г. снижалось, при увеличении числа операций. При сравнении частоты встречаемости осложнений разной локализации чаще всего встречаются осложнения, локализованные на нижней челюсти, наименее часто в подбородочном отделе. При сравнении частоты встречаемости осложнений разного типа за период 20122017 гг. было выявлено, что травма нижнечелюстного нерва встречается наиболее часто. Также часто встречаются такие осложнения, как неудовлетворительное позиционирование мыщелкового отростка нижней челюсти и неконтролируемый перелом челюстей. При сравнении встречаемости осложнений разного класса тяжести в отдельные годы указанного периода было выявлено, что чаще всего встречаются осложнения класса III, наименее часто осложнения класса I. Заключение. Минимизация осложнений во время операции достигается путем составления четкого плана основанного на тщательной предоперационной диагностике. Данный вид хирургического лечения относится к категории сложных реконструктивных операций, и одним из критериев хорошего результата ортогнатической операции является наличие большого опыта как у оперирующего хирурга, так и у операционной бригады в целом.
Purpose of the study. The main task of orthognathic surgery is to achieve facial harmony and correction of skeletal deformities of the jaw and occlusion. In orthognathic surgery, pre-surgical preparation, surgical planning and post-surgical orthodontic management of the patient are indispensable. At various stages of treating patients, various errors and complications may occur. The main objective of this study is to analyze the complications of surgical treatment of patients at the intraoperative stage a comparison of the structure of operations according to the frequency of complications in certain years of the period 2012-2017 comparison of the frequency of complications of different localization comparing the frequency of complications of varying severity and creating a modern working classification of complications. Material and methods. In the period from 2012 to 2017, 1329 orthognathic surgeries were performed in the Department of Maxillofacial and Plastic Surgery of the MSUMD. All patients admitted to the clinic of MSUMD were consulted by the maxillofacial surgeons together with orthodontists and related specialists according to indications. Comprehensive examination of patients included a clinical examination, examination of the face and oral cavity, anthropometric examination of the face and gypsum models of the jaws, X-ray examination of the maxillofacial region (computed tomography), photometric examination of the patients face, magnetic resonance imaging of the temporomandibular joint (MRI of the TMJ). Among 1329 operations, 89 clinical cases of intraoperative complications were identified. Among intraoperative complications during operations on the maxilla there were bleeding (damage to the maxillary artery, palatine arteries and their branches) damage or fracture of the roots of the teeth (when installing mini-screws or segmental osteotomy) uncontrolled fracture lines of osteotomated bone fragments (in the area of the hillocks of the upper jaw and pterygoid plate of the sphenoid bone) deviation of the nasal septum with insufficient resection and mobilization of the septum during the rotation of the upper jaw perforation of the mucous membrane of the hard palate with sharp instruments for segmental osteotomy breaking off the reciprocating saw during the formation of the line of osteotomy. In osteotomy of the lower jaw, damage to the mandibular nerve (rupture or incision with sharp surgical instruments) was encountered bleeding (damage to the mandibular vessels) uncontrolled fracture lines of osteotomated bone fragments (in the condylar process, body and lower jaw branch) unsatisfactory displacement and positioning of the condylar process with genioplasty poor positioning of the chin relative to the cosmetic center. Based on the data of the Department of Maxillofacial and Plastic Surgery, and data from the world literature, a classification of intraoperative complications of surgical treatment of patients with congenital anomalies of the jaw was compiled and proposed. In the classification, complications were divided by localization (upper jaw, lower jaw, chin) and severity: Class I (adverse events that did not require a fundamental change in the tactics of the operation and did not lead to further consequences for the patient) Class II (adverse events with possible further consequences for the patient) Grade III (adverse events that often were not recognized on time, therefore, their correction was not carried out during the operation and entailed significant consequences for the patient). The results of the study. According to the results, the frequency of complications over the years was statistically significantly different: in 2015 there were fewer complications than in 2012 in 2016 there were fewer complications than in 2012 and 2013. Thus, the number of complications decreased from 2012 to 2017, with an increase in the number of operations. When comparing the frequency of occurrence of complications of different localization, the most common complications are localized in the lower jaw, the least often in the chin. When comparing the frequency of occurrence of complications of various types for the period 2012-2017, it was revealed that trauma of the mandibular nerve is most common. Complications such as poor positioning of the condylar process of the lower jaw and uncontrolled fracture of the jaw are also common. When comparing the incidence of complications of different severity classes in certain years of the indicated period, it was revealed that most often complications of class III, least often, complications of class I. Conclusion Minimization of complications during surgery is achieved by drawing up a clear plan based on a thorough preoperative diagnosis. To prevent neurosensory deficiency of various areas of the face and trauma of the mandibular nerve, an assessment of the location of the nerve should be performed according to the results of a computer tomogram. The intraoperative treatment of rupture of the mandibular nerve is its crosslinking with monofilament thread 6/0. To prevent an unsatisfactory fracture of the jaw, it is recommended to remove the third molars at least 6 months before the operation, due to their location in the cut line of the lower jaw. It is necessary to clearly follow the methods for splitting jaw fragments. As a treatment for an uncontrolled fracture of jaw fragments, osteosynthesis is performed with additional mini-plates. Recommended manual control of the correct position of the condylar processes when positioning the lower jaw, satisfactory closure of the dentition, in the absence of the latter - re-fixation of bone fragments for the prevention of dysfunction of the temporomandibular joint. With rupture and the formation of a defect in the nasal mucosa during its detachment on the upper jaw, subsequent suturing is performed. Prevention of tooth root injury with a drill is ensured by the presence of a certain distance between the roots of the teeth by an orthodontist at the preoperative stage. In the presence of a root fracture or exacerbation of chronic periodontitis, the injured tooth is removed. In the presence of perforation of the tooth root with a drill, its endodontic treatment is performed. This type of surgical treatment belongs to the category of complex reconstructive operations, and one of the criteria for a good result of orthognathic surgery is the great experience of both the operating surgeon and the operating team as a whole.