Prevention of complications after the surgical treatment of the facial fractures

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RELEVANCE
Maxillofacial injury (MTI) is a public health problem due to its high prevalence and the need for resources to treat it, as well as the financial and social impact of MFT victims on the healthcare system. According to A.G. Shargorodsky and N.M. Stefantsev [1] over the past decades, there has been a significant increase in the number of injuries to the bones of the facial skeleton in the population. In addition to the growth of damage to the bones of the facial skull, the very structure of injuries of the maxillofacial region has also changed: there is a trend towards an increase in the number of multiple combined fractures [2].
Infectious-inflammatory complications after surgery, otherwise infections associated with the provision of medical care (Healthcare associated infections - HAIS), according to various sources, account for 15–20% of all nosocomial infections, of which 30–80% occur after discharge from the hospital [ 3, 4, 5]. To prevent secondary infection, antibiotic therapy is used in the postoperative period, but it cannot fully prevent postoperative suppuration, since antibiotics act only on the microflora, excluding the influence of local and general factors on wound healing processes [6, 7, 4, 5].
Thus, one of the causes of complications is negative reactions at the “plate-bone” interface, where the interphase layer determines the optimal processes of bone tissue regeneration. To prevent the influence of local factors on the development of secondary infection, biologically active and inert materials are being searched as an alternative to steel and titanium products [8, 6, 9]
Section 1 Analysis of existing approaches.
Currently, the most common surgical intervention for fractures of the bones of the maxillofacial region is osteosynthesis with miniplates and screws made of titanium alloys. This type of operations allows for rigid fixation of fragments for the required period and their complete immobilization. These are plates made by Champy from stainless steel (17.2% Cr, 14% Ni), as well as plates from titanium alloys from Champy, Leibinger, De Pue, Stratec/AO.
Pure titanium is not used for the manufacture of bone plates due to insufficient physical, mechanical and strength properties. Titanium alloys 6AL4V and 6AL4V ELI are titanium alloyed with 6% aluminum and 4% vanadium. They are used to make plates, pins, pins used for osteosynthesis, as they can withstand heavy loads [10]. Titanium nickelide, or nitinol, a thermal memory material, is an alloy containing 55% nickel and 45% titanium. When using open methods of surgical treatment, skeletonization of the fracture area, reposition and fixation of the bones are performed.
According to Onoprienko G.A., 2017 [11], stable osteosynthesis, which provides optimal conditions for reparative osteogenesis, has become dominant in the modern system of treatment of bone injuries. The generally accepted devices (products) for the formation of osteo-fibrous-cartilaginous callus are a reflection of the nature of the reparative process in any conditions, including unfavorable ones, and the development of their shape, alloy and surface.
However, it should be noted that surgical intervention exacerbates the risk of secondary infection of the wound in the postoperative period. To date, the volume of complications in the postoperative period is significant [12]. In addition to infectious complications, one should single out such an undesirable phenomenon as the development of metallosis and galvanic effects in individuals who have a combination of different grades of steel and/or titanium in the plate and fasteners [13].
Section 2 New Developments
To prevent complications after surgical treatment of trauma to the facial skeleton, researchers took the path of creating protective films on titanium and using bioresorbable plates and screws. However, it should be noted that these studies are few. Does C.S. et al [14] compared the surgical feasibility, functional outcome, and fixation stability between a conventional miniplate and a three-dimensional plate in the treatment of unilateral mandibular subcondylar fractures in adults. A prospective, randomized clinical trial has been conducted, which has shown the undeniable advantage of using a three-dimensional plate, providing excellent stability of fracture fragments and less displacement of fractured segments. An additional advantage is the ease of adaptation and shorter run times.
Dorri M. et al. [15] in their review shows that there are currently no published randomized controlled clinical trials. There is currently insufficient evidence for the effectiveness of resorbable fixation systems compared to conventional titanium systems in facial fractures. The conclusions of this review, based on the results of the aborted tests, do not suggest that resorbable plates are as effective as titanium plates. Probably in the future, the results of ongoing clinical trials can provide high-level, reliable evidence to help clinicians and patients make decisions. Berger M.B. et al., [16] showed in their study that material surface design can influence osteogenesis and immune responses in vitro. Surface modifications can be created using a variety of techniques on 2D surfaces, but the literature supports the hypothesis that those surfaces that exhibit signs of ostilastic bone resorption—depressions, roughness, and complex hierarchical structures at the submicron and nanoscale—are more effective in supporting differentiation of osteoblasts in vitro and osteogenesis in vivo. The growing use of advanced manufacturing for the production of implants with complex three-dimensional structures may require the development of new ways to create these biomimetic surface topographies. The study of SiC coating showed that this material can be applied to various surfaces (acrylic resins, tantalum). The high modulus of elasticity, combined with mechanical strength and resistance to abrasion and dissolution, make SiC coatings promising for use in orthopedic dentistry. The biocompatibility of SiC coatings has been proven by in vitro studies on cell lines and models of organs and body media, as well as experimental studies involving laboratory animals. Thus, studies have justified the development of clinical research and the development of effective approaches to the use of SiC in medicine and near-medical sciences. [17, 18] There is information about the use of similar SiC films in neurology and cardiology [19]. inside the bone tissue and its surrounding structures, is one of the key factors in the development of purulent-inflammatory complications in the postoperative period. It is known that the less microorganisms are capable of adhesion and colonization of the implant material, the less likely it is to develop peri-implantitis. The intraosseous part of the implant is practically unable to contact the microbial ecological environment of the body. Contact with bacteria is possible mainly at the time of implant placement. The presence of statistically significant differences between the percentages of residual adhesion of strains of obligate anaerobic bacteria to a titanium alloy with a protective coating proves the feasibility of using a coating applied by ion-plasma spraying to prevent complications [20]. One of the options for solving the problem of post-surgical complications is the use of ion-plasma miniplate and screw coatings. The experimental data of Demyanova A.V. demonstrated statistically valid results in reducing the incidence and severity of complications among patients with injuries of the lower jaw. In the group using standard sets for maxillofacial surgery, miniplates, screws and drills coated with ion-plasma coating, the bone tissue remained intact. Patients in the control group showed signs of severe inflammation, and the inflammatory process spread along the vessels. the presence of productive purulent inflammation in histological examination revealed pronounced cell proliferation, characterized by the presence of polymorphic cell infiltrates and destructive foci with purulent exudate. [20] CONCLUSION Thus, it can be concluded that, based on the results of microbiological, clinical, histological and statistical studies, it is possible to recommend the use of this method to a practicing physician, namely, extrafocal osteosynthesis with titanium miniplates and screws coated with silicon carbide in the treatment of fractures of the bones of the facial skull . Especially in cases with a high risk of developing postoperative complications, in the treatment of infected fractures of the facial bones with inflammation in the area of ​​the fracture and in late treatment of patients, performing simultaneous surgical intervention when opening osteogenic foci of inflammation and osteosynthesis of bone fragments, or performing it as soon as possible after opening purulent focus when it is impossible to conduct one-stage osteosynthesis. However, it is the method of choice in the treatment of fractures of the bones of the facial skull.

Funding source. The study was not supported by any external sources of funding.

Competing interests. The authors declare that they have no competing interests.

Author contribution. All authors made a significant contribution to the preparation of the article, read and approved the final version before publication. Professor Amkhadova M.A. belongs to the idea of writing the article. 

About the authors

Anastasia V. Demyanova

Odintsovo District Hospital No. 2

Email: nastazzzy@mail.ru
ORCID iD: 0000-0001-8836-0497

MD, Cand. Sci. (Med.)

Russian Federation, Perkhushkovo

Malkan A. Amkhadova

Moscow Regional Research and Clinical Institute

Email: amkhadova@mail.ru
ORCID iD: 0000-0002-9105-0796
SPIN-code: 3018-7883

MD, Dr. Sci. (Med.), Professor

Russian Federation, Moscow

Elena Ivanova

Moscow Regional Research and Clinical Institute

Email: 77712022@mail.ru
ORCID iD: 0000-0002-6330-6942
SPIN-code: 5569-7339

MD, Dr. Sci. (Med), Associate Professor

Russian Federation, Moscow

Vladimir I. Demyanov

Odintsovo District Hospital No. 2

Email: vldemyanov@mail.ru
ORCID iD: 0000-0003-3711-4573

MD, Cand. Sci. (Med.)

Russian Federation, Perkhushkovo

Islam S. Amkhadov

Moscow Regional Research and Clinical Institute

Author for correspondence.
Email: islam_amhadov@list.ru
ORCID iD: 0000-0003-2973-8351

MD, Cand. Sci. (Med.)

Russian Federation, Moscow

References

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