Purpose: Treating comminuted mandib

Purpose: Treating comminuted mandibular fractures remains a challenge. In this study, we used
titanium mesh to treat comminuted mandibular fractures.
Materials and Methods: Nine patients with traumatically comminuted mandibular fractures who
received open reduction and internal stable fixation with titanium mesh were retrospectively reviewed.
Open reduction–internal stable fixation was performed 7 to 10 days after primary debridement of the facial
trauma. After the fractured mandible and the displaced fragments were reduced, the titanium mesh was
reshaped according to the morphology of the mandible, and the reduced bone fragments were fixed
with the reshaped titanium mesh and screws. Then, the surgical effects were evaluated during routine
follow-up.
Results: Most of the displaced fragments were reserved and exhibited a favorable shaping ability in
restoring the morphology of the mandible during surgery. Q3 No intraoperative complications were encountered. In addition, all patients were infection free, with no obvious resorption in the fixed fragments after
surgery. The mandible also exhibited favorable morphology and offered sufficient bone mass for dental
implantation or a denture prosthesis.
Conclusions: We conclude that titanium mesh shaping and fixation can effectively treat comminuted
mandibular fractures with little bone fragment loss, little soft tissue exposure, a low infection rate, and
favorable mandibular morphology.
Although there are a considerable number of treatment methods for comminuted mandibular fractures,
treating such fractures remains a challenge because
of the high infection rate, unsatisfactory mandibular
shape, and loss of bone fragments. Treatment
methods include closed reduction; external pin fixation; internal wire fixation; and open reduction and
internal stable fixation (ORIF) using miniplates,
reconstruction plates, or screws.
1-3
It was
previously believed that open surgery impairs the
precarious vascularity to the bone fragments, which
results in sequestration and infection, and that
comminuted mandibular fractures should be treated
in a closed manner to prevent the stripping of the
blood supply from the fragments.
1,2
However,
Kazanjian and many other researchers stated that
stabilization of the fragments was the most
important factor in obtaining an osseous union of
comminuted fragments, rather than the initial loss
of bone, and ORIF with plates or screws has thus become a mainstream method for treating
comminuted fractures.
1
Q5
Two principles in bone fracture fixation, that is, the
need to support full functional loads and the need to
retain the absolute stability of the fracture construct,
play crucial roles in sound bone healing and maintaining a low rate of infection. However, the load-sharing
osteosynthesis between the implant and bone cannot
be achieved when using limited plates or screws in
comminuted fractures. Furthermore, discouraging reports from past experiences with ORIF using wires,
mini-plates, or even reconstruction plates have been
associated with infection, which has resulted in substantial bone loss and associated morbidity.
3,4
Q6 Q7
Although there is a lack of extensive reports on
comminuted mandibular fractures, previous studies
have reported some surgical complications that
occurred after ORIF of comminuted mandibular
fractures. Iizuka et al
5
reported an infection rate of
6.1% when using the AO/ASIF principle of rigid fixation. Kuriakose et al
6
compared ORIF using 2.7-mm
AO/ASIF reconstruction plates with miniplates, and a
substantial difference in the incidence of infection between the 2 groups was seen (30% with miniplates vs
14.3% with reconstruction plates). Scolozzi and
Richter
7
reported a 3% infection rate when 2.4-mm
AO titanium reconstruction plates were applied to
treat severe mandibular fractures. In addition, the
preservation of bone fragments and the restoration
of mandibular shape were difficult to achieve by using
plates or screws.
7
Q8
Comminuted mandibular fractures have been
treated in our department using a number of techniques, including closed reduction and ORIF. Over
the past 5 years, we also have treated bone defects using autologous iliac bone with titanium mesh, and we
have used titanium mesh shaping and fixation to treat
comminuted mandibular fractures. To our surprise,
good treatment results have been shown, including a
low infection rate, favorable mandibular morphology,
little soft tissue exposure, and little loss of bone
fragments. The purpose of this study was to retrospectively evaluate our experience in treating
comminuted mandibular fractures using titanium mesh.
Materials and Methods
PATIENTS
This study was performed in the department of oral
and craniomaxillofacial surgery at our hospital. The
registries of patients with traumatically comminuted
mandibular fractures receiving ORIF at our hospital
during the past 4 years (2011 through 2014) were
retrospectively reviewed. Informed consent to participate in this study was obtained from each patient,
and all patients who appear in the figures gave full
permission for their images to be used in this publication. The study protocol followed the guidelines of the
Declaration of Helsinki and was approved by the
Ethics Committee of Shanghai Ninth People’s Hospital,

Shanghai Jiaotong University School of Medicine. All of
the experiments described in this article were performed in accordance with the guidelines and regulations issued by the Ethics Committee of Shanghai
Ninth People’s Hospital, Shanghai Jiaotong University
School of Medicine. The medical charts or records of
the enrolled patients were retrieved and subjected to
further review to obtain information regarding patient
demographic data and clinical features.
The definitive diagnosis of a traumatically comminuted mandibular fracture was made largely based
on clinical examination findings, radiographic features, and computed tomography (CT) examination
findings, and comminuted fractures were defined as
fractures with more than 2 free bone fragments.
Nine patients with traumatically comminuted mandibular fractures who received ORIF with titanium mesh
were included in this study (Fig 1). The patient group
comprised 8 male patients and 1 female patient aged
between 13 and 41 years (mean, 27.448.26 years).
Basic information about these patients is shown in
Table 1. Use of titanium mesh and other alternative
methods, including ORIF using reconstruction plates
and miniplates, was presented to all the patients preoperatively. The patients then made their own decisions based on full disclosure of the advantages and
disadvantages of the techniques.
SURGICAL PROCEDURE
The ORIF surgical procedure for comminuted
mandibular fractures was performed 7 to 10 days after
primary debridement. Primary debridement aimed to
stop the bleeding, close the wound in the oral cavity,
clean the area around the fracture regions, and maintain the occlusal relationship using intermaxillary fixation (IMF) under general or local anesthesia. If a
combined maxillary fracture was present, we also performed ORIF for the maxillary fracture during the primary operation to obtain a favorable occlusal relationship (Fig 2). All ORIF surgical procedures were
performed with patients under general endotracheal
anesthesia. The procedure was initiated by making
an extraoral submandibular incision or an incision
along the primary extraoral wound to expose the fractured mandible and fragments and to avoid contact
with the intraoral bacterial conditions. Then, the fractured mandible and the displaced fragments were
reduced. Subsequently, the titanium mesh, with a
thickness of 0.6 mm (Stryker, Kalamazoo, MI), was reshaped according to the morphology of the mandible,
and the reduced bone fragments were fixed with the
reshaped titanium mesh and screws. For some patients, the larger mandibular segments were fixed
with miniplates (Fig 3). During surgery, the restoration
of primary occlusion is a standard procedure for bone
reduction. Finally, the extraoral wound was sutured
layer by layer with No. 3-0 and 5-0 absorbable sutures
and No. 6-0 polyglactin 910 sutures (Vicryl; Ethicon,
Somerville, NJ). Q9 Antibiotic prophylaxis with cefotiam
was used and maintained for all patients for 3 days after
surgery. All patients required IMF for 7 to 10 days after surgery.
POSTOPERATIVE EVALUATION
The clinical examination and craniofacial CT data
from the 9 patients were retrospectively analyzed at
routine follow-up intervals of 3, 6, and 12 months.
The wound condition, resorption condition of the
bone fragments, mandibular morphology, and mandibular function were chosen to evaluate the surgical effects.
Results
Detailed information about the patients is shown in
Table 1. There were 6 patients with comminuted
mandibular fractures in the symphyseal region and 3
patients with comminuted mandibular fractures in
both the mandible body and symphyseal region. Four
patients simultaneously had comminuted mandibular fractures and condylar fractures, and 1 patient simultaneously had comminuted mandibular fractures and
zygomatic-maxillary fractures. Complicated condylar
fractures were treated with ORIF using miniplates or
long screws, and zygomatic-maxillary fractures
received ORIF using miniplates. Q10
During surgery, the extraoral incision offered a clean
approach for the reduction and fixation of the fractured mandible. Most of the displaced fragments
were preserved and fixed, and no autogenous or heterogeneous bone was needed to fill the defect. In addition, the titanium mesh exhibited good shaping ability,
and the favorable morphology of the mandible was
restored during surgery (Fig 3). No intraoperative complications were encountered. The operation time from
the incision to the fixation of the displaced fragment of
the fractured mandible (including fixation) was
454.52 minutes.
The postoperative mandibular morphology and function were evaluated by clinical examination and CT
exami

結果 (繁體中文) 1:

目的: 治療下頜骨粉碎性的骨折仍是一個挑戰。在此研究中，我們使用鈦網治療下頜骨粉碎性的骨折。材料和方法: 正粉碎性下頜骨骨折 9 例誰回顧分析收到的開放重定、 鈦網內部穩定固定。開放的減少 — — 內部穩定的固定進行面部清創後 7 到 10 天精神創傷。減少裂縫性下頜骨和流離失所者的碎片之後，鈦網是重塑下頜骨的表面形貌和降低的骨碎片被固定螺釘與重塑的鈦網。然後，手術效果被評估了在常式採取後續行動。結果: 大部分流離失所者碎片保留，表現出良好的成形能力在在手術過程中恢復下頜骨的形態。第 3 季度無術中併發症。此外，所有患者感染免費的沒有明顯的吸收後固定碎片中手術。下頜骨也表現出良好的形態及提供足夠的骨量的口腔科植入或義齒的修復。結論: 鈦網成形和固定能有效地治療粉碎性下頜骨骨折與根小骨頭碎片損失、 小軟組織暴露、 低感染率，和有利的下頜骨形態。雖然有為數可觀的下頜骨骨折的治療方法治療此類骨折仍是一個挑戰因為感染率之高，令人不滿意的下頜形狀和損失的骨頭碎片。治療方法包括閉合的重定;外部引腳固定;內部導線固定;和重定和內部穩定的固定 (ORIF) 使用微型鋼板，重建鋼板或螺釘。1-3它是以前認為，開放手術損害不穩定血管對骨頭碎片，其中結果在隔離和感染，應該治療下頜骨粉碎性的骨折在封閉的方式，以防止被剝奪片段的血液供應。1，2然而，卡贊晉和許多其他研究人員指出，穩定的碎片是最在獲得骨癒合的重要因素粉碎的片段，而不是最初的損失骨，和切開重定內的固定與鋼板或螺釘已因此成為一種治療的主流方法粉碎性的骨折。1Q5在骨骨折內固定，那就是，兩個原則需要支援的需要以及全功能的負荷保留的斷裂構造的絕對穩定性在健全的骨癒合和維持較低的感染率發揮至關重要的作用。然而，負載共用內的固定植入物與骨之間不能當使用有限板或螺釘實現粉碎性的骨折。此外，令人沮喪的報告從過去的經驗與切開重定內固定使用電線，微型鋼板或甚至重建牌已與感染，已造成大量骨損失和相關發病率相關聯。3，4Q6 Q7雖然上有廣泛的報告缺乏下頜骨粉碎性的骨折，先前的研究有報導一些手術的併發症，發生後切開重定內固定粉碎性下頜骨骨折。塚 et al5報導的感染率6.1 當使用剛性固定的 AO/ASIF 原則 %。庫利亞科 et al6使用 2.7 毫米相比切開重定內固定AO/ASIF 重建鋼板接骨，和在 2 組間感染的發生率的堅固區別是見 (30%與微型鋼板 vs重建鋼板 14.3%)。斯科洛齊和裡希特7報導 3%感染率時 2.4 毫米AO 鈦板重建被應用於治療嚴重下頜骨骨折。此外，保存的骨頭碎片和恢復下頜骨的形狀很難通過使用實現鋼板或螺釘。7Q8下頜骨粉碎性的骨折已經在我們的部門使用的一些技術，包括閉合的重定和切開重定內固定治療。結束過去的 5 年中，我們也有治療骨缺損鈦網與我們使用自體髂骨已用於鈦網成形和固定治療下頜骨骨折。令我們吃驚的是，很好的治療結果表明，包括低感染率，良好的下頜骨形態，小小的軟組織暴露和骨損失小碎片。本研究的目的是回顧性評價治療的經驗使用鈦網的下頜骨粉碎性的骨折。材料和方法病人這項研究進行口腔系和我們醫院顱頜面外科。的登記冊的患者正粉碎下頜骨骨折切開重定內的固定在我們醫院接收在過去的 4 年 (2011 年至 2014 年)回顧性分析。知情同意權參與這項研究是從每個病人，獲得所有出現在數位的病人全給了他們的圖像得以此出版物中使用的許可權。研究協定遵循的準則赫爾辛基宣言並已獲上海第九人民醫院醫院倫理委員會上海上海交通大學大學醫學院臨床醫學專業。所有的在這篇文章中所描述的實驗進行按照準則和規章出具上海倫理委員會第九人民醫院、 上海交通大學醫學院。醫療圖表或記錄登記的患者檢索和遭受進一步的審查，以獲得有關病人的資訊人口統計資料和臨床特點。正的下頜骨骨折的明確診斷了很大程度上基於對臨床檢驗結果、 影像學特徵及電腦斷層掃描 (CT) 檢查結果和粉碎性的骨折被定義為超過 2 游離骨塊骨折。九患者正粉碎性下頜骨骨折切開重定內固定與鈦網被列入本研究 (圖 1)。患者組包括 8 例男性患者和 1 名女病人年齡13 到 41 歲之間 (平均，27.44 8.26 年)。這些患者的基本資訊所示表 1。使用鈦網和其他替代方法，包括使用重建板切開重定內固定和微型鋼板，提出了對所有患者術前。病人然後作出自己的決定基於充分披露的優點和技術的缺點。外科手術切開重定內固定手術治療粉碎性下頜骨骨折是執行的 7 至 10 天后清創。清創的目的止血，關閉在口腔內，傷口周圍骨折區域，區域的清潔和維護使用頜間固定 (國際貨幣基金組織) 的咬合關係一般或局部麻醉下。如果結合上頜骨骨折在場，我們在主要的操作，以獲得良好的咬合關係 (圖 2) 期間上, 頜骨骨折，也執行切開重定內固定。所有切開重定內固定手術performed with patients under general endotrachealanesthesia. The procedure was initiated by makingan extraoral submandibular incision or an incisionalong the primary extraoral wound to expose the fractured mandible and fragments and to avoid contactwith the intraoral bacterial conditions. Then, the fractured mandible and the displaced fragments werereduced. Subsequently, the titanium mesh, with athickness of 0.6 mm (Stryker, Kalamazoo, MI), was reshaped according to the morphology of the mandible,and the reduced bone fragments were fixed with thereshaped titanium mesh and screws. For some patients, the larger mandibular segments were fixedwith miniplates (Fig 3). During surgery, the restorationof primary occlusion is a standard procedure for bonereduction. Finally, the extraoral wound was suturedlayer by layer with No. 3-0 and 5-0 absorbable suturesand No. 6-0 polyglactin 910 sutures (Vicryl; Ethicon,Somerville, NJ). Q9 Antibiotic prophylaxis with cefotiamwas used and maintained for all patients for 3 days aftersurgery. All patients required IMF for 7 to 10 days after surgery.POSTOPERATIVE EVALUATIONThe clinical examination and craniofacial CT datafrom the 9 patients were retrospectively analyzed atroutine follow-up intervals of 3, 6, and 12 months.The wound condition, resorption condition of thebone fragments, mandibular morphology, and mandibular function were chosen to evaluate the surgical effects.ResultsDetailed information about the patients is shown inTable 1. There were 6 patients with comminutedmandibular fractures in the symphyseal region and 3patients with comminuted mandibular fractures inboth the mandible body and symphyseal region. Fourpatients simultaneously had comminuted mandibular fractures and condylar fractures, and 1 patient simultaneously had comminuted mandibular fractures andzygomatic-maxillary fractures. Complicated condylarfractures were treated with ORIF using miniplates orlong screws, and zygomatic-maxillary fracturesreceived ORIF using miniplates. Q10During surgery, the extraoral incision offered a cleanapproach for the reduction and fixation of the fractured mandible. Most of the displaced fragmentswere preserved and fixed, and no autogenous or heterogeneous bone was needed to fill the defect. In addition, the titanium mesh exhibited good shaping ability,and the favorable morphology of the mandible wasrestored during surgery (Fig 3). No intraoperative complications were encountered. The operation time fromthe incision to the fixation of the displaced fragment ofthe fractured mandible (including fixation) was454.52 minutes.The postoperative mandibular morphology and function were evaluated by clinical examination and CTexami

結果 (繁體中文) 2:

用途：治療粉碎性下頜骨骨折仍是一個挑戰。在這項研究中，我們用
鈦網治療粉碎性下頜骨骨折。
材料和方法：9例誰外傷粉碎性骨折下頜骨骨折
。接受開放復位內固定牢靠鈦網進行回顧性分析
切開復位，內固定牢靠進行7〜 10天后面部的首要清創術
的創傷。後的斷裂頜骨和移位片段減少，鈦網被
按照下頜骨的形態重塑，減骨片段固定
與重整的鈦網和螺釘。然後，在日常進行了評價手術效果
隨訪。
結果：大多數流離失所片段被保留並展出了良好的成形能力，
在手術過程中恢復下頜骨的形態。Q3無術中並發症遇到。另外，所有患者均感染自由的，沒有明顯的吸收，在固定的片段後
手術。下頜骨也表現出良好的形態，並提供足夠的骨量為牙齒
植入或假牙修復體。
結論：我們的結論是鈦網塑形和固定可有效治療粉碎性
下頜骨骨折小骨片的損失，有點軟組織暴露，低感染率和
良好的下頜的形態，
雖然有相當數量的處理方法粉碎下頜骨骨折，
治療這類骨折仍然因為挑戰
的高感染率， ​​不滿意下頜的
形狀，和骨頭碎片損失。治療
方法包括閉合復位; 外部引腳固定; 內部電線固定; 和切開復位
用接骨板，內部穩定的固定（ORIF）
重建板，或螺絲
。1-3
據
先前認為，開腹手術損害
不穩定血管到骨頭碎片，這
導致在隔離和感染，而且
粉碎頜骨骨折應被視為
在一個封閉的方式，以防止的汽提
血供來自片段
。1,2-
然而
，Kazanjian 和許多其他研究人員指出，
這些片段的穩定化是最
重要的因素在獲得的骨癒合
粉碎碎片，而比初始損失
骨的，並與板或螺釘切開復位內固定有因而成為主流方法用於治療
粉碎骨折
。1
Q5
在骨骨折固定兩個原則，即，
需要支持全部的功能載荷和需要
保留的絕對骨折構建體穩定性，
在聲音骨癒合中起關鍵作用，並保持感染率低。然而，負載共享
植入物與骨之間接合術不能
在使用有限的板或螺釘時實現
粉碎性骨折。此外，從過去的經驗與切開復位內固定用線材，抑制報告
微型板，或甚至重建板已經被
感染，這也導致大量骨損失和相關的發病率有關
。3,4-
Q6 Q7
雖然缺乏廣泛的報告在
粉碎下頜骨骨折，以往的研究
已經報導了一些手術並發症的
粉碎下頜骨切開復位內固定後發生
骨折。飯塚等
5
報導的感染率
6.1％，採用剛性固定的AO / ASIF原則時。Kuriakose等
6
比切開復位內固定使用2.7毫米的
AO / ASIF重建鋼板與接骨板，以及
2組之間的感染的發病率顯著差異，看到（30％接骨板VS
14.3％，與重建鋼板）。Scolozzi和
裡氏
7
報導了3％的感染率在2.4毫米
被應用AO鈦合金重建鋼板來
治療嚴重的下頜骨骨折。此外，
骨碎片的保存和恢復
下頜形狀都是難以實現通過使用
板或螺釘
。7
Q8
粉碎頜骨骨折已
在我們部門使用多種技術，包括閉合復位切開復位內固定處理。在
過去的5年中，我們也已經處理過的骨缺損採用自體髂骨與鈦網，我們
已經使用鈦網塑形和固定治療
粉碎性下頜骨骨折。令我們驚訝的是，
良好的治療效果已被證明，包括
感染率低，有利於下頜的形態，
有點軟組織暴露，和骨損耗小
片段。這項研究的目的是回顧性評價治療我們的經驗
粉碎下頜骨骨折採用鈦網。
材料和方法
患者
於口服部門進行這項研究
，並顱頜面外科在我們的醫院。該
患者有外傷粉碎登記
接收切開復位內固定在我們的醫院下頜骨骨折
在過去4年（2011年至2014年）進行了
回顧性分析。從每個病人獲得知情同意參加本次研究中，
並顯示在人物誰所有患者給予了充分的
本出版物中使用自己的形象的許可。研究方案遵循的準則
赫爾辛基宣言，並批准了
上海第九人民醫院的倫理委員會，上海交通大學醫學院。所有在這篇文章中所描述的實驗是按照由上海的倫理委員會發出的指引和法規的規定執行第九人民醫院，上海交通大學醫學院。的病歷或記錄已登記的患者進行檢索，並進行進一步審查，以獲取有關病人信息的人口統計數據和臨床特徵。一個創傷性粉碎性骨折下頜骨骨折的明確診斷為主要依據臨床檢查結果，影像學特徵，並計算斷層掃描（CT）檢查結果，以及粉碎性骨折被定義為骨折超過2個免費的骨頭碎片。9 例誰收到切開復位內固定鈦網外傷粉碎性下頜骨骨折被納入本次研究（圖1）。病人組包括8例男性患者和1女患者年齡在13和41歲之間（平均27.44 8.26？年）。這些患者的基本信息如表1。使用鈦網和其他替代的方法，包括使用重建切開復位內固定板和接骨板，呈獻給所有患者術前。患者再依據充分披露的優點，並提出自己的決定的技術缺點。外科手術的切開復位內固定手術的粉碎是後7〜10天進行下頜骨骨折主要的清創術。主清創的目的是止血，關閉傷口在口腔，清理周圍的斷裂區的面積，並保持使用在全身或局部麻醉間固定（IMF）的咬合關係。如果一個組合上頜斷裂存在，我們還進行切開復位內固定用於上頜骨折主操作過程中獲得有利的咬合關係（圖2）。所有切開復位內固定手術方法是進行下一般患者氣管內全麻。該程序是通過啟動一個口外頜下切口或切口沿主口外傷口暴露下頜骨骨折和片段，並避免接觸與口腔內的細菌條件。然後，斷裂下頜骨和移位片段減少。接著，將鈦網，具有厚度為0.6毫米（斯瑞克，卡拉馬祖，MI）是按照下頜骨的形態重塑，和減少骨片段固定有重整的鈦網和螺釘。對於一些患者，較大的下頜節段固定用接骨板（圖3）。在手術中，恢復主閉塞是一個標準過程骨減少。最後，口外傷口縫合逐層與第3-0和5-0可吸收縫合線和第6-0聚乳糖910縫線（薇喬;愛惜康，薩默維爾，新澤西州）。Q9預防性抗生素頭孢替安與使用和維護所有患者術後3天手術。所有患者在手術後需要國際貨幣基金為7至10天。術後評估的臨床檢查和顱面CT數據從9例在回顧性分析常規隨訪間隔3，6和12個月。傷口條件，再吸收的條件的骨碎片，下頜形態和下頜功能被選擇來評估手術的效果。結果有關患者的詳細信息顯示在表1中有6例粉碎在沿恥骨聯合區域頜骨骨折和3 例在粉碎頜骨骨折無論是下頜骨體及沿恥骨聯合區。四例患者同時粉碎了下頜骨骨折和髁狀突骨折，1例患者同時有粉碎性骨折下頜骨骨折及顴骨，上頜骨骨折。複雜的髁突骨折患者使用切開復位內固定接骨板或處理過的長螺絲，顴骨，上頜骨骨折用接骨板收到切開復位內固定。Q10 在手術過程中，口外切口提供了一個乾淨的方式對下頜骨骨折的復位和固定。大多數流離失所片段被保存並固定，且無自體或異種骨是需要的填充缺損。此外，鈦網顯示出良好的成形能力，和下頜骨的有利形態手術（圖3）中恢復。無術中並發症遇到。從動作時間切口的位移片段的固定骨折下頜骨（包括固定）為45？4.52分鐘。術後下頜的形態和功能通過臨床檢查和CT進行評價exami