Доктор ахборотномаси № 2 (99)—2021
80
DOI: 10.38095/2181-466X-2021992-80-84 UDK 616.31:616.716.4-001-5-089
OPTIMIZATION OF THE MAIN ASPECTS OF ANATOMICAL, FUNCTIONAL AND
SOCIAL REHABILITATION OF PATIENTS WITH MANDIBULAR FRACTURES
Z. K. Rakhimov, F. F. Ne’matova
Bukhara state medical institute, Bukhara, Uzbekistan
Key words:
post-traumatic osteomyelitis, fracture, lower jaw, infection, inflammation.
Таянч сўзлар:
травмадан сўнгги остеомиелит, синиш, пастки жағ, инфекция, яллиғланиш.
Ключевые слова:
посттравматический остеомиелит, перелом, нижняя челюсть, инфекция, воспаления.
Post-traumatic osteomyelitis is a very common complication of a fracture of the mandible: 10–12% of patients
with fractures of the mandible develop tissue suppuration in the area of bone damage, accompanied by necrosis of the
wound surfaces of the fragments with the formation of sequesters. To solve this problem, a significant number of
methods and means are used, however, the number of infectious and inflammatory processes in the post-traumatic
period continues to remain high, which significantly complicates the treatment of victims.
ПАСТКИ ЖАҒИ СИНГАН БЕМОРЛАРДА АСОСИЙ АНАТОМИК, ФУНКЦИОНАЛ ВА ИЖТИМОИЙ
РЕАБИЛИТАЦИЯ ЖИҲАТЛАРИНИ МАҚБУЛЛАШТИРИШ
З. К. Рахимов, Ф. Ф. Неъматова
Бухоро давлат тиббиѐт институти, Бухоро, Ўзбекистон
Жароҳатдан кейинги остеомиелит- бу пастки жағ суяги синишларида тез-тез учрайдиган асорат бўлиб,
пастки жағ суяги синган беморларнинг 10-12% жароҳатланган суяк соҳасида тўқима йирингланишини риво-
жлантиради ва шу билан яра юзалари некрози, секвестрларнинг шаклланиши билан бирга кечади. Ушбу муам-
мони ҳал этиш учун жуда кўп усул ва дори воситалардан фойдаланилса ҳам травматик остемиелитдан кейинги
даврда, инфекцион-яллиғланиш даволашдан кейин муаммолигича қолмоқда.
ОПТИМИЗАЦИЯ ГЛАВНЫХ АСПЕКТОВ АНАТОМИЧЕСКОЙ, ФУНКЦИОНАЛЬНОЙ И
СОЦИАЛЬНОЙ РЕАБИЛИТАЦИИ ПАЦИЕНТОВ С ПЕРЕЛОМАМИ НИЖНЕЙ ЧЕЛЮСТИ
З. К. Рахимов, Ф. Ф. Неъматова
Бухарский государственный медицинский институт, Бухара, Узбекистан
Посттравматический остеомиелит — весьма распространенное осложнение при переломе нижней челю-
сти: у 10–12% пациентов с переломами нижней челюсти в зоне повреждения кости развивается нагноение тка-
ней, сопровождающееся некрозом раневых поверхностей отломков с образованием секвестров. Для решения
этой проблемы используется значительное количество методов и средств, однако число инфекционно-
воспалительных процессов в посттравматическом периоде продолжает оставаться высоким, что значительно
осложняет лечение пострадавших.
Relevance.
Mandibular fractures and their treatment are one of the topical problems in max-
illofacial surgery. Among all injuries to the bones of the face, such fractures amount, according to
different authors, from 45 to 90.9%. The frequent development of abscesses and phlegmon in the
head and neck region is due to the high prevalence of chronic focal odontogenic, tonsilogenic in-
fections, as well as infectious and inflammatory lesions of the skin and oral mucosa.
The most common form of septic inflammation is odontogenic purulent-inflammatory dis-
eases. The high incidence of infectious and inflammatory complications in fractures of the jaw
bones remains. In recent decades, interest in acute infections of the face and neck has increased
due to the increase in the number of patients with these diseases and the number of severe intra-
and extracranial complications [1, 4, 5, 6].
The search for new effective, pathogenetically substantiated methods of therapy for pyo-
inflammatory diseases (PID) of the maxillofacial region (MFR) is one of the most difficult prob-
lems of modern pediatric surgery. Features of the anatomy of childhood, poorly expressed general
and local immunity to the pyogenic flora are prerequisites for the more frequent occurrence, rapid
development and severe course of inflammatory diseases in comparison with adults [7].
A common task in the treatment of patients with purulent-inflammatory processes of the
lower jaw is the inclusion of a set of therapeutic measures aimed at both the patient's div and
pathogens.
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Treatment of purulent-inflammatory processes is based on the complex conduct of surgical
interventions and conservative measures. Surgical intervention, which consists in the obligatory
opening of a purulent focus and their rational drainage. Opening of abscesses is carried out by in-
cisions over the affected foci, which provides a free outflow of pus and exudate, reduces pressure
in infiltrated tissues, normalizes microcirculation and early removal of necrotic tissues, and also
helps to suppress microflora directly in the pathological focus and accelerates regeneration pro-
cesses [2, 8].
After good drainage, the wound is repeatedly washed with solutions of antiseptics (furacilin,
potassium permanganate, dimexide, exterioricide, etc.) of antibiotics, surfactants (chlorhexedine,
rocal, etc.). One of the effective local methods of cleansing the wound from microbes and toxins,
as well as tissue decay products, is wound dialysis, which actively affects the healing processes,
improves functional results and shortens the treatment period for patients.
In order to quickly cleanse the wound, dioxidine, dimethyl sulfoxide, oxacilin, chloroaceto-
phos and levomecolic ointments, proteinolytic enzymes are used topically. A common disad-
vantage of various ointments used in the treatment of purulent-inflammatory diseases is that they
are based on fat. In this regard, the ointments do not mix with the wound exudate and cannot ab-
sorb the wound discharge, which adversely affects the processes of cleansing and healing the
wound in the initial stages. Apparently in the initial stages of the inflammatory process, it is better
to use drugs in the form of solutions, and after cleansing the wound and in the absence of dis-
charge from it, use ointment preparations.
In recent years, a number of works have appeared on the successful application of a number
of physical factors in local therapy, which helps to cleanse and heal wounds, and shorten the dura-
tion of treatment.
In the complex of therapeutic measures in the treatment of patients with purulent-
inflammatory diseases, especially in the presence of anaerobic infection, hyperbaric oxygenation is
increasingly used, the effectiveness of which is primarily associated with the acceleration of local
and general hypoxia, as well as the creation of hyperoxia, which has a detrimental effect on aer-
obes and a number of anaerobes , at the same time increases the activity of antibiotics. The main
component of the complex of general therapy is the use of antibacterial drugs. General therapy for
pyoinflammatory diseases of the maxillofacial region (MFR) begins immediately after the opera-
tion with intramuscular or intravenous antibiotics.
The unsolved issues of the urgent problem of providing specialized medical care to patients
with various forms of pathology of the maxillary artery were the subject of this study in order to
substantiate the organizational and complex of therapeutic measures aimed at optimizing the ana-
tomical, functional and social rehabilitation of patients with fractures of the mandible.
Materials and research methods.
The present study included the results of examination
and treatment of 94 people. Among them, 63 patients with a unilateral fracture and 31 patients
with a bilateral fracture of the lower jaw, who were hospitalized at the Bukhara regional multidis-
ciplinary medical center in the clinic of surgical dentistry in Bukhara in the period from 2011 to
2020.
The control group consisted of 31 people from practically healthy people of the same age.
The age of the surveyed ranged from 17 to 62 years. Among them, most were men - 59 people
(65%), women - 35 (35.0%). Table 1 shows the distribution of patients by sex and age (Table 1).
Patients in most cases received injuries as a result of wounds and surgical actions, which
amounted to 48.9% (46 cases), then domestic injuries 19 cases (20.2%), sports injuries 13 (13.8%),
transport 9 (9,5%) and occupational injuries accounted for 7.4% (7 cases).
Of all patients, 33 (35.1%) were hospitalized on the first day, within 2-3 days - 18 (19.1%),
and at a later date - 8 (8.5) patients.
The terms of admission of patients to the hospital are presented in Table 2.
Of those examined, 59 patients had a unilateral fracture of the mandible, and 35 were diag-
nosed with a bilateral fracture of the mandible.
Z. K. Rakhimov, F. F. Ne’matova
Доктор ахборотномаси № 2 (99)—2021
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Table 2.
Terms of admission of patients to the clinic from the moment of injury.
All patients were hospitalized for urgent reasons.
Analysis of the literature data and the results of our research indicate that the most common
complaints of an inflammatory nature in purulent-inflammatory diseases include pain in the area
of swelling, weakness, malaise, sleep and appetite disturbances, and fever.
The general condition of patients with pyoinflammatory diseases was satisfactory in 36
(38.3%), moderate in 48 (51.0%), severe in 10 (10.7%). Body temperature ranged from 36.8°C to
39.5°C.
The clinical picture in patients was characterized by the presence of an inflammatory infil-
trate in the damaged area. The general reaction of the div was expressed in proportion to the
spread and nature of the local purulent process.
Complaints of patients mainly consisted of general cerebral and local symptoms and
amounted to pain in the area of the mandible fracture in 59 (62.7%), 59 (62.7%) - general weak-
ness, 66 cases of irritability, which amounted to 70.2% sick (Table 3).
№
Up to 20 years
20-29
30-39
40-49
50 and older
Total
1 Men
9
20
16
8
6
59 (62,7 %)
2 Women
6
12
14
3
0
35 (37,3 %)
3 Total
15
32
30
11
6
94 (100%)
Table 1.
№
1 day
2 days
3 days
4 days
5 days
Total
1 Unilateral fracture
LJ
33
12
6
2
6
59 (62,7%)
2 Bilateral fracture
LJ
15
2
6
4
8
35 (37,3%)
Total
48
14
12
6
14
94 (100%)
№
Symptoms
Total
%
1
LJ fracture area pain
59
62,7
2
Swelling of soft tissues
67
71,3
3
Hematoma in the area of the LJ fracture
48
51,1
4
Purulent fusion of soft tissues (abscess and phlegmon)
79
84
5
Destruction of bone tissue
63
67,2
6
Fistulas
15
15,9
7
Restriction of mouth opening
65
69,1
8
General weakness
59
62,7
9
Irritability
66
70,2
10 Rupture of the oral mucosa (OM)
73
78,7
Table 3.
Frequency of occurrence of general and local symptoms in the examined patients upon admission
The main local symptoms in patients on admission were in the area of the LJ (in 100% of
patients) and the presence of swelling of soft tissues (71.3%). All patients also noted difficulty in
chewing food, and in 65 (69.1%) patients, mouth opening was limited due to severe pain.
Examination of the oral cavity in patients showed a rupture of the oral mucosa in 73 (78.7%)
as a result of displacement of fragments; in 48 (51.1%) patients, hematomas or bruises of the mu-
cous membrane in the area of the mandibular fracture were noted.
The main pyoinflammatory complications in the fracture of the LJ were abscess in 23
(24.4%) cases, phlegmon in 56 (59.5%) fistulas - in 15 (15.5%) cases.
On examination, all patients with phlegmon showed hyperemia of the skin, swelling and in-
filtration of soft tissues. From the side of the oral cavity, there is also edema and infiltration of the
mucous membrane and periosteum, submucosal or subperiosteal abscesses can form. There are no
radiological signs of osteomyelitis in the acute stage on radiographs of the lower jaw. Not earlier
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Table 1.
The nature of changes in the activity of lysosomal enzymes of neutrophils in patients with pyoinflam-
matory complications against the background of a fracture of the mandible.
than two weeks after the development of inflammatory phenomena in the bone, the expansion of
the fracture gap with signs of osteoporosis is radiologically determined, and sequesters of different
shapes and sizes are found along the line of damage to the jaw.
The symptom of fluctuation was observed in 44 (46.8%) patients, in 46 (48.9%) - a sharp
soreness of the surrounding soft tissues, pain during swallowing was observed in 4 (4.3%) pa-
tients. The study of microflora from a purulent focus in patients for aerobes was carried out in 94
patients, of whom
St. epidermidis
was sown in 63 (67, 02%),
St. aureus
in 13 (13.8%), in 15
(15.9%) cases
St. viridans
and in 13 (13.8%) cases aerobic growth was obtained.
Also, our studies have shown that the development of this complication is preceded by func-
tional changes in the microvasculature. A decisive role in the development of post-traumatic osteo-
myelitis is played by infection of the damaged area of the jaw by the microflora of the oral cavity
or by bacterial contamination from the outside in violation of the epithelial integument. The devel-
opment of post-traumatic osteomyelitis of the jaw is facilitated by a violation of the trophism of
tissues in the damaged zone, which occurs due to the possible compression of the lower alveolar
nerve by bone fragments. In addition, galvanic corrosion of dissimilar metals from which intrale-
sional fasteners are made can lead to the development of post-traumatic osteomyelitis.
In studies of the activity of hydrolytic enzymes of neutrophil lysosomes in patients with frac-
tures of the mandible, very important shifts in the system of proteolytic activity of blood serum
were established. The essence of these shifts lies in the fact that with the development of purulent-
inflammatory complications in patients with fractures of the lower jaw, the activity of RNase and
cathepsin D acids naturally increases (Table 4.) cathepsin is the cleavage of peptide bonds.
In addition, the protease under study is involved in the inactivation of a number of enzymes,
hormones, biologically active proteins and peptides. An important role is also played by such pro-
tealytic enzymes of neutrophil lysosomes as acid and alkaline phosphatase, DNase. These enzymes
are released from microphages not only during the breakdown of these cells, but also under the
action of fragments of the complement system (C3a, C5a) and immune complexes.
The purulent-inflammatory process in patients with fractures of the lower jaw was accompa-
nied by a pronounced increase in the activity of the studied lysosomal enzymes of polymorphonu-
clear neutrophils. Thus, in this group of patients, an increase in the activity of acid phosphatase by
6 times, DNase by 24% was noted, on the contrary, the activity of alkaline phosphatase tended to
decrease by 2.4 times. Of no small importance is also the value of medium molecular weight pep-
tides (MMWP) in the blood of patients with fractures of the mandible. High values of the level of
MMWP in patients with fractures of the mandible (FM) indicated an unfavorable clinical course of
the inflammatory process, since they are toxic and thereby reduce local resistance [8].
Examining the level of immune complexes in the examined patients, we found a significant
(P <0.05) increase in the latter. Apparently one of the main causes of tissue damage in pyoinflam-
matory complications is the release of lysosomal enzymes under the action of immune complexes.
Indicators
Healthy faces
Patients on admission
The number of polymorphonuclear neutrophils (%)
56.0+2.01
78.0+1.43
Cathepsin D activity (
μ
mol/min/g protein)
5.5+0.51
10.8+0.91
RNase (
μ
mol / min/g protein)
61.4+1.27
78.6+3.12
DNase (
μ
mol / min/g protein)
121.0+2111
149.6+35.1
Acidphosphatose (UA)
1.1+0.09
6.6+0.51
Alkalinephosphatose (UA)
5.3+0.41
2.4+0.21
Circulating immune complexes (conventional units)
35.4+2.71
78.0+5.11
MMWP (conventional units)
0.28±0.06
0.58±0.06
Z. K. Rakhimov, F. F. Ne’matova
Доктор ахборотномаси № 2 (99)—2021
84
Conclusions:
1. Intensive antibiotic therapy for purulent-inflammatory complications may be complicated
by the development of toxic shock caused by the simultaneous death and decay of a larger number
of microorganisms. Therefore, in the tactics of treating such patients, it is necessary to include en-
zyme preparations along with antibacterial therapy, as a result of which the dose of the antibiotic
used will be significantly reduced and this will achieve a prolonged effect.
2. Of the examined, 59 patients had a unilateral fracture of the mandible, and 35 were diag-
nosed with a bilateral fracture of the mandible. The analysis of the research results showed that the
most common complaints of an inflammatory nature in case of purulent-inflammatory complica-
tions of fractures of the mandible are in the first days after the injury, and after 7-10 days, the pa-
tient's condition deteriorates. an increase in symptoms of intoxication, weakness, malaise, sleep
and appetite disorders, increased div temperature. Increasing pain in the area of the fracture, in-
flammatory infiltration of soft tissue and fracture gap. Clinical symptoms of the formation of a pu-
rulent focus in the peri-jaw soft tissues, the presence of a non-extracted tooth that prevents the re-
lease of pus into the fracture gap. From the side of the oral cavity there is edema and infiltration of
the mucous membrane and periosteum, submucosal or periosteal abscesses may develop. On the
radiographs of the lower jaw, there are no radiological signs of osteomyelitis in the acute stage.
Not earlier than two weeks after the development of inflammatory phenomena in the bone, the ex-
pansion of the fracture gap with signs of osteoporosis is radiologically determined, and sequesters
of various shapes and sizes are found along the line of damage to the jaw.
3. Thus, in the mechanism of the described biochemical changes in pyoinflammatory com-
plications against the background of a fracture of the mandible, the following main points can be
distinguished: the formation of immune complexes, activation of the complement system, activa-
tion of lysosomal neutrophil enzymes, increased vascular permeability, and impaired microcircula-
tion. The latter aggravates the above violations and can activate the hemostatic system.
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Оригинальная статья